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News ReleaseMonday, September 6, 2021A genomic analysis of lung cancer in people with no buy kamagra without prescription history of smoking has found that a majority of these tumors arise from the accumulation of mutations caused by natural processes in low price kamagra the body. This study was conducted by an international team led by researchers at the National Cancer Institute (NCI), part of the National Institutes of Health (NIH), and describes for the first time three molecular subtypes of lung cancer in people who have never smoked. These insights will help unlock the mystery of how lung cancer low price kamagra arises in people who have no history of smoking and may guide the development of more precise clinical treatments. The findings were published September 6, 2021, in Nature Genetics. €œWhat we’re seeing is that there are different subtypes of lung cancer in never smokers that have distinct molecular characteristics and evolutionary processes,” said epidemiologist Maria Teresa Landi, M.D., Ph.D., of the Integrative Tumor Epidemiology Branch in NCI’s Division of Cancer Epidemiology and Genetics, who led the study, which was done in collaboration with researchers at the National Institute of Environmental Health Sciences, another part of NIH, and other institutions.

€œIn the future we may be able low price kamagra to have different treatments based on these subtypes.” Lung cancer is the leading cause of cancer-related deaths worldwide. Every year, more than 2 million people around the world are diagnosed with the disease. Most people who develop lung cancer have a history of tobacco smoking, but 10% to 20% of people who develop lung cancer have never smoked. Lung cancer in never smokers occurs more frequently in women and at an earlier age than lung cancer in smokers low price kamagra. Environmental risk factors, such as exposure to secondhand tobacco smoke, radon, air pollution, and asbestos, or having had previous lung diseases, may explain some lung cancers among never smokers, but scientists still don’t know what causes the majority of these cancers.

In this large epidemiologic low price kamagra study, the researchers used whole-genome sequencing to characterize the genomic changes in tumor tissue and matched normal tissue from 232 never smokers, predominantly of European descent, who had been diagnosed with non-small cell lung cancer. The tumors included 189 adenocarcinomas (the most common type of lung cancer), 36 carcinoids, and seven other tumors of various types. The patients had not yet undergone treatment for their cancer. The researchers combed the tumor genomes for mutational signatures, which are patterns of mutations associated with specific mutational processes, such as damage from natural activities in the body (for example, faulty DNA repair or oxidative stress) or from exposure to carcinogens low price kamagra. Mutational signatures act like a tumor’s archive of activities that led up to the accumulation of mutations, providing clues into what caused the cancer to develop.

A catalogue of known mutational signatures now exists, although some signatures have no known cause. In this study, the researchers discovered that a majority of the tumor genomes of never smokers bore mutational signatures associated with damage from endogenous processes, that is, natural processes low price kamagra that happen inside the body. As expected, because the study was limited to never smokers, the researchers did not find any mutational signatures that have previously been associated with direct exposure to tobacco smoking. Nor did they find those signatures among the 62 patients who had been exposed to secondhand tobacco smoke. However, Dr low price kamagra.

Landi cautioned that the sample size was small and the level of exposure highly variable. €œWe need a larger sample size with detailed information on low price kamagra exposure to really study the impact of secondhand tobacco smoking on the development of lung cancer in never smokers,” Dr. Landi said. The genomic analyses also revealed three novel subtypes of lung cancer in never smokers, to which the researchers assigned musical names based on the level of “noise” (that is, the number of genomic changes) in the tumors. The predominant low price kamagra “piano” subtype had the fewest mutations.

It appeared to be associated with the activation of progenitor cells, which are involved in the creation of new cells. This subtype of tumor grows extremely slowly, over many years, and is difficult to treat because it can have many different driver mutations. The “mezzo-forte” subtype had specific chromosomal changes as well as low price kamagra mutations in the growth factor receptor gene EGFR, which is commonly altered in lung cancer, and exhibited faster tumor growth. The “forte” subtype exhibited whole-genome doubling, a genomic change that is often seen in lung cancers in smokers. This subtype low price kamagra of tumor also grows quickly.

€œWe’re starting to distinguish subtypes that could potentially have different approaches for prevention and treatment,” said Dr. Landi. For example, the slow-growing piano subtype could give clinicians a window of opportunity to detect these tumors earlier low price kamagra when they are less difficult to treat. In contrast, the mezzo-forte and forte subtypes have only a few major driver mutations, suggesting that these tumors could be identified by a single biopsy and could benefit from targeted treatments, she said. A future direction of this research will be to study people of different ethnic backgrounds and geographic locations, and whose exposure history to lung cancer risk factors is well described.

€œWe’re at the beginning of understanding how low price kamagra these tumors evolve,” Dr. Landi said. This analysis shows that there is heterogeneity, or diversity, in lung cancers in never smokers.” Stephen J. Chanock, M.D., director of NCI’s Division of Cancer Epidemiology and Genetics, noted, “We expect this detective-style investigation of genomic tumor characteristics to unlock new avenues of discovery for low price kamagra multiple cancer types.” The study was conducted by the Intramural Research Program of NCI and National Institute of Environmental Health Sciences. About the National Cancer Institute (NCI).

NCI leads the National Cancer Program and NIH’s efforts to dramatically reduce the prevalence of cancer and improve the lives of cancer patients and their families, through low price kamagra research into prevention and cancer biology, the development of new interventions, and the training and mentoring of new researchers. For more information about cancer, please visit the NCI website at cancer.gov or call NCI’s contact center, the Cancer Information Service, at 1-800-4-CANCER (1-800-422-6237).About the National Institutes of Health (NIH):NIH, the nation's medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare low price kamagra diseases. For more information about NIH and its programs, visit www.nih.gov.

NIH…Turning Discovery Into Health®###A study published today by researchers at the National Institutes of Health revealed that about half of individuals who said they don’t want to receive secondary genomic findings changed their mind after their healthcare provider gave them more detailed information. The paper, published in Genomics in Medicine, examines people's attitudes about receiving low price kamagra secondary genomic findings related to treatable or preventable diseases. The study was led by scientists at the National Human Genome Research Institute (NHGRI) and the National Institute of Environmental Health Sciences (NIEHS), both part of NIH. Your browser does not support the video tag. Animation of patient filling out an informed consent form and checking the "YES" checkboxes for both Expected low price kamagra Outcome and Secondary Findings.

Credit. Ernesto del Aguila low price kamagra III, NHGRI. With the broader adoption of genome sequencing in clinical care, researchers and the bioethics community are considering options for how to navigate the discovery of secondary genomic findings. Secondary findings that come out of genome sequencing reflect information that is separate from the primary reason for an individual's medical care or participation in a study. For example, the genomic data of a patient who undergoes genome sequencing to address an autoimmune problem might reveal genomic variants that are associated with a low price kamagra heightened risk for breast cancer.

Based on the American College of Medical Genetics and Genomics recommendations in 2021, individuals who have their genomes sequenced for a clinical reason should also be screened for genomic variants in 73 genes, including BRCA1 and BRCA2, both of which are linked to an increased risk of breast and ovarian cancer. All 59 genes are associated with treatable or potentially severe diseases. Proponents of a person’s right to not know their secondary genomic findings have argued that, to maintain autonomy, individuals should have the opportunity to decide whether low price kamagra to be provided information about genomic variants in these additional genes. "Because these genomic findings can have life-saving implications, we wanted to ask the question. Are people really understanding what they low price kamagra are saying no to?.

If they get more context, or a second opportunity to decide, do they change their mind?. " said Benjamin Berkman, J.D., M.P.H., deputy director of the NHGRI Bioethics Core and senior author on the study. The research group worked with participants from low price kamagra the Environmental Polymorphisms Registry, an NIEHS study examining how genetic and environmental factors influence human health. Out of 8,843 participants, 8,678 elected to receive secondary genomic findings, while 165 opted out. Researchers assessed those 165 individuals to determine how strongly and consistently they maintained their "right not to know" decision.

The researchers low price kamagra wanted to determine whether providing additional information to people about their genomic variants influenced their decision and to better understand why some people still refused their secondary genomic findings after they received the additional information. Following the intervention, the researchers found that the 165 people sorted into two groups. "reversible refusers" who switched their decision to accept to know their secondary genomic findings and "persistent refusers" who still refused. Because these genomic findings can have life-saving implications, we wanted to ask low price kamagra the question. Are people really understanding what they are saying no to?.

If they get more context, or low price kamagra a second opportunity to decide, do they change their mind?. "It is worth noting that nearly three-quarters of reversible refusers thought they had originally agreed to receive secondary genomic findings," said Will Schupmann, a doctoral candidate at UCLA and first author on the study. "This means that we should be skeptical about whether checkbox choices are accurately capturing people’s preferences.” Based on the results, the researchers question whether healthcare providers should ask people who have their genome sequenced if they want to receive clinically important secondary genomic findings. Investigators argue that enough data supports a default practice of returning secondary genomic findings without first low price kamagra asking participants if they would like to receive them. But research studies should create a system that also allows people who do not want to know their secondary genomic findings to opt out.

The researchers suggest that if healthcare providers actively seek their patients’ preferences to know or not know about their secondary genomic findings, the providers should give the individuals multiple opportunities to make and revise their choice. "The right not to know has been a contentious topic in the genomics research community, but we believe that our real-world data can help move the field low price kamagra towards a new policy consensus," said Berkman. Researchers at the NIH Department of Bioethics, NIEHS, Harvard University and Social &. Scientific Systems collaborated on the study..

News ReleaseMonday, September 6, 2021A genomic analysis of lung cancer in http://metallicwebsites.net/?post_type=wpcf7_contact_form&p=4 people with no history of smoking has found that generic kamagra online a majority of these tumors arise from the accumulation of mutations caused by natural processes in the body. This study was conducted by an international team led by researchers at the National Cancer Institute (NCI), part of the National Institutes of Health (NIH), and describes for the first time three molecular subtypes of lung cancer in people who have never smoked. These insights will help unlock the mystery of how lung cancer generic kamagra online arises in people who have no history of smoking and may guide the development of more precise clinical treatments. The findings were published September 6, 2021, in Nature Genetics.

€œWhat we’re seeing is that there are different subtypes of lung cancer in never smokers that have distinct molecular characteristics and evolutionary processes,” said epidemiologist Maria Teresa Landi, M.D., Ph.D., of the Integrative Tumor Epidemiology Branch in NCI’s Division of Cancer Epidemiology and Genetics, who led the study, which was done in collaboration with researchers at the National Institute of Environmental Health Sciences, another part of NIH, and other institutions. €œIn the future we may be able to generic kamagra online have different treatments based on these subtypes.” Lung cancer is the leading cause of cancer-related deaths worldwide. Every year, more than 2 million people around the world are diagnosed with the disease. Most people who develop lung cancer have a history of tobacco smoking, but 10% to 20% of people who develop lung cancer have never smoked.

Lung cancer in never smokers occurs more frequently in women and at an earlier age than lung cancer in smokers generic kamagra online. Environmental risk factors, such as exposure to secondhand tobacco smoke, radon, air pollution, and asbestos, or having had previous lung diseases, may explain some lung cancers among never smokers, but scientists still don’t know what causes the majority of these cancers. In this large epidemiologic study, the researchers used whole-genome sequencing to characterize the genomic changes in tumor tissue and matched normal tissue from 232 never smokers, generic kamagra online predominantly of European descent, who had been diagnosed with non-small cell lung cancer. The tumors included 189 adenocarcinomas (the most common type of lung cancer), 36 carcinoids, and seven other tumors of various types.

The patients had not yet undergone treatment for their cancer. The researchers combed the tumor genomes for mutational signatures, which are patterns of mutations associated with specific mutational processes, such as damage from natural activities in the body (for example, faulty DNA repair or oxidative stress) generic kamagra online or from exposure to carcinogens. Mutational signatures act like a tumor’s archive of activities that led up to the accumulation of mutations, providing clues into what caused the cancer to develop. A catalogue of known mutational signatures now exists, although some signatures have no known cause.

In this study, the researchers discovered that a majority of the tumor genomes of never smokers bore mutational signatures associated with damage from generic kamagra online endogenous processes, that is, natural processes that happen inside the body. As expected, because the study was limited to never smokers, the researchers did not find any mutational signatures that have previously been associated with direct exposure to tobacco smoking. Nor did they find those signatures among the 62 patients who had been exposed to secondhand tobacco smoke. However, Dr generic kamagra online.

Landi cautioned that the sample size was small and the level of exposure highly variable. €œWe need a larger generic kamagra online sample size with detailed information on exposure to really study the impact of secondhand tobacco smoking on the development of lung cancer in never smokers,” Dr. Landi said. The genomic analyses also revealed three novel subtypes of lung cancer in never smokers, to which the researchers assigned musical names based on the level of “noise” (that is, the number of genomic changes) in the tumors.

The predominant generic kamagra online “piano” subtype had the fewest mutations. It appeared to be associated with the activation of progenitor cells, which are involved in the creation of new cells. This subtype of tumor grows extremely slowly, over many years, and is difficult to treat because it can have many different driver mutations. The “mezzo-forte” subtype had specific chromosomal changes as well as mutations in the growth factor receptor gene EGFR, which is commonly altered in lung cancer, and exhibited faster tumor growth generic kamagra online.

The “forte” subtype exhibited whole-genome doubling, a genomic change that is often seen in lung cancers in smokers. This subtype of tumor generic kamagra online also grows quickly. €œWe’re starting to distinguish subtypes that could potentially have different approaches for prevention and treatment,” said Dr. Landi.

For example, the slow-growing piano subtype could give clinicians generic kamagra online a window of opportunity to detect these tumors earlier when they are less difficult to treat. In contrast, the mezzo-forte and forte subtypes have only a few major driver mutations, suggesting that these tumors could be identified by a single biopsy and could benefit from targeted treatments, she said. A future direction of this research will be to study people of different ethnic backgrounds and geographic locations, and whose exposure history to lung cancer risk factors is well described. €œWe’re at the generic kamagra online beginning of understanding how these tumors evolve,” Dr.

Landi said. This analysis shows that there is heterogeneity, or diversity, in lung cancers in never smokers.” Stephen J. Chanock, M.D., director of NCI’s Division of Cancer Epidemiology generic kamagra online and Genetics, noted, “We expect this detective-style investigation of genomic tumor characteristics to unlock new avenues of discovery for multiple cancer types.” The study was conducted by the Intramural Research Program of NCI and National Institute of Environmental Health Sciences. About the National Cancer Institute (NCI).

NCI leads generic kamagra online the National Cancer Program and NIH’s efforts to dramatically reduce the prevalence of cancer and improve the lives of cancer patients and their families, through research into prevention and cancer biology, the development of new interventions, and the training and mentoring of new researchers. For more information about cancer, please visit the NCI website at cancer.gov or call NCI’s contact center, the Cancer Information Service, at 1-800-4-CANCER (1-800-422-6237).About the National Institutes of Health (NIH):NIH, the nation's medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the generic kamagra online causes, treatments, and cures for both common and rare diseases.

For more information about NIH and its programs, visit www.nih.gov. NIH…Turning Discovery Into Health®###A study published today by researchers at the National Institutes of Health revealed that about half of individuals who said they don’t want to receive secondary genomic findings changed their mind after their healthcare provider gave them more detailed information. The paper, published in Genomics in Medicine, examines people's attitudes about receiving secondary genomic findings related to treatable or preventable generic kamagra online diseases. The study was led by scientists at the National Human Genome Research Institute (NHGRI) and the National Institute of Environmental Health Sciences (NIEHS), both part of NIH.

Your browser does not support the video tag. Animation of patient filling out an informed generic kamagra online consent form and checking the "YES" checkboxes for both Expected Outcome and Secondary Findings. Credit. Ernesto del Aguila III, NHGRI generic kamagra online.

With the broader adoption of genome sequencing in clinical care, researchers and the bioethics community are considering options for how to navigate the discovery of secondary genomic findings. Secondary findings that come out of genome sequencing reflect information that is separate from the primary reason for an individual's medical care or participation in a study. For example, the genomic data of a patient who undergoes genome sequencing to address an autoimmune problem might reveal genomic variants that are associated with a heightened risk for breast generic kamagra online cancer. Based on the American College of Medical Genetics and Genomics recommendations in 2021, individuals who have their genomes sequenced for a clinical reason should also be screened for genomic variants in 73 genes, including BRCA1 and BRCA2, both of which are linked to an increased risk of breast and ovarian cancer.

All 59 genes are associated with treatable or potentially severe diseases. Proponents of a person’s right to not know their secondary genomic findings have argued that, to maintain autonomy, individuals generic kamagra online should have the opportunity to decide whether to be provided information about genomic variants in these additional genes. "Because these genomic findings can have life-saving implications, we wanted to ask the question. Are people really understanding what they are saying no generic kamagra online to?.

If they get more context, or a second opportunity to decide, do they change their mind?. " said Benjamin Berkman, J.D., M.P.H., deputy director of the NHGRI Bioethics Core and senior author on the study. The research group worked with participants from the Environmental Polymorphisms Registry, an NIEHS study examining how genetic and environmental factors generic kamagra online influence human health. Out of 8,843 participants, 8,678 elected to receive secondary genomic findings, while 165 opted out.

Researchers assessed those 165 individuals to determine how strongly and consistently they maintained their "right not to know" decision. The researchers wanted to determine whether providing additional information to people about their genomic variants influenced their decision and to better understand why some people still refused their secondary genomic findings after they received the additional information generic kamagra online. Following the intervention, the researchers found that the 165 people sorted into two groups. "reversible refusers" who switched their decision to accept to know their secondary genomic findings and "persistent refusers" who still refused.

Because these genomic findings can generic kamagra online have life-saving implications, we wanted to ask the question. Are people really understanding what they are saying no to?. If generic kamagra online they get more context, or a second opportunity to decide, do they change their mind?. "It is worth noting that nearly three-quarters of reversible refusers thought they had originally agreed to receive secondary genomic findings," said Will Schupmann, a doctoral candidate at UCLA and first author on the study.

"This means that we should be skeptical about whether checkbox choices are accurately capturing people’s preferences.” Based on the results, the researchers question whether healthcare providers should ask people who have their genome sequenced if they want to receive clinically important secondary genomic findings. Investigators argue that enough generic kamagra online data supports a default practice of returning secondary genomic findings without first asking participants if they would like to receive them. But research studies should create a system that also allows people who do not want to know their secondary genomic findings to opt out. The researchers suggest that if healthcare providers actively seek their patients’ preferences to know or not know about their secondary genomic findings, the providers should give the individuals multiple opportunities to make and revise their choice.

"The right not to know has been a contentious topic in the genomics research community, but we believe that our real-world data can help generic kamagra online move the field towards a new policy consensus," said Berkman. Researchers at the NIH Department of Bioethics, NIEHS, Harvard University and Social &. Scientific Systems collaborated on the study..

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This web tool presents a summary of fetal and infant deaths, with a focus on generic kamagra online deaths and stillbirths registered in 2017. Information presented includes demographic information (eg, ethnicity and sex), cause of death, gestation and birthweight, as well as deaths classified as sudden infant death syndrome (SIDS) and sudden unexpected death in infancy (SUDI).Key findings for 2017 Overview There were 390 fetal deaths and 284 infant deaths registered in 2017. This equates to a fetal death rate of 6.4 per 1000 total births and an infant generic kamagra online death rate of 4.7 per 1000 live births. Between 1996 and 2017, there was a significant decrease in the infant death rate.

The rate fell from 7.3 to 4.7 generic kamagra online per 1000 live births. This decrease was primarily due to a notable decrease in post-neonatal deaths. Over the same time period, the fetal generic kamagra online death rate was between 6.0 and 8.5 per 1000 total births. Births trend Between 2008 and 2017, the total number of births decreased by around 7%.

The total number of births each year can influence the rate of fetal and infant deaths generic kamagra online. Ethnic group There was no significant difference in fetal death rates between ethnic groups in 2017, consistent with the previous five-year period. Fetal death rates by generic kamagra online ethnicity were similar between 2012 to 2017. Infant death rates in 2017 were highest for the Pacific peoples and Māori ethnic groups (8.7 and 5.9 per 1000 live births, respectively).

These rates were significantly higher than rates for the European or Other and Asian ethnic groups (3.4 and 3.7 per 1000 live births, generic kamagra online respectively). Similar differences were seen in the previous five years. Maternal age group There was no significant difference in fetal death rates between maternal age groups. In 2017, the infant death generic kamagra online rate was highest among women aged between 20 and 24 years (6.8 per 1000 live births).

In the previous five-year period (2012–2016), the infant death rate for babies of women aged less than 20 years was significantly higher than for babies of women in all other age groups. Socioeconomic deprivation In 2017, there were generic kamagra online no significant differences in fetal death rates between levels of deprivation. The highest infant death rates in 2017 were for the most deprived areas (quintile 5). In the most deprived areas, generic kamagra online the infant death rate was more than twice the rate of the least deprived areas (quintile 5, 6.6 per 1000 live births and quintile 1, 2.7 per 1000 live births).

This is consistent with the previous five-year period (2012–2016). Gestation Approximately 80% of fetal deaths and 69% of infant deaths registered in 2017 were preterm (<37 weeks’ gestation), the majority of which were generic kamagra online very preterm (<28 weeks’ gestation). Birthweight Approximately 60% of fetal deaths registered in 2017 had a birthweight of less than 1000 g, and approximately 30% had a birthweight of less than 500 g. Approximately 50% of generic kamagra online infant deaths had a birthweight of less than 1000 g, and approximately 20% weighed 500–999 g at birth.

Sudden unexpected death in infancy (SUDI) There were 48 sudden unexpected death in infancy (SUDI) deaths in 2017, including 28 sudden infant death syndrome (SIDS) deaths. The SUDI deaths included 28 males generic kamagra online and 20 females. The SUDI rate in 2017 was 0.8 per 1000 live births. In each year in the period 2013–2017, the SUDI rate was generic kamagra online either 0.7 or 0.8 per 1000 live births.

In the five-year period 2013–2017, SUDI rates for babies in the Māori and Pacific peoples ethnic groups were significantly higher than the rates for babies in the Asian and European or Other ethnic groups. SUDI rates for babies of mothers aged less than 25 years were significantly higher than for those mothers in all other age groups. The SUDI rate for babies born in the most deprived areas (quintile 5) was significantly higher generic kamagra online than the rate for all other deprivation quintiles. Note.

The number of fetal generic kamagra online and infant deaths in New Zealand is small and may cause rates to fluctuate markedly from year to year. Rates derived from small numbers should be interpreted with caution. About the data used in this edition This dataset is a continuation generic kamagra online of the Fetal and Infant Deaths series. At the time the data was extracted there were 11 infant deaths awaiting coroners' findings.

These deaths may be assigned a provisional code based on limited information available at the time, while deaths with no known cause awaiting coroners’ findings are coded to R99, ‘Other ill-defined and unspecified causes generic kamagra online of mortality’, or X59, ‘Exposure to unspecified factor’. Deaths for which a cause is still to be determined or confirmed will be updated in the next edition of Fetal and Infant Deaths as the coroners complete their findings. Disclaimer In this edition, deaths data was extracted and recalculated for the years 2008–2017 to reflect ongoing updates to data in the New generic kamagra online Zealand Mortality Collection (for example, following the release of coroners’ findings). For this reason, there may be small changes to some numbers and rates from those presented in previous publications and tables.

We have generic kamagra online quality checked the collection, extraction, and reporting of the data presented here. However, errors can occur. Contact the Ministry of Health if you have any concerns regarding any of the data or analyses presented here, at [email protected]..

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Michael Capalbo used to subsist mostly on have a peek at this site meals in restaurants and takeouts.“I just thought I was immortal,” viagra or kamagra says the 54-year-old Connecticut salesman. €œI was literally living on burgers and wings and pizza and stuff like that.”Then in April of 2020, while at work at Walgreens, Capalbo had a massive heart attack caused viagra or kamagra by a complete blockage in a major artery. A pharmacist gave him an aspirin and called 911. Capalbo later learned that viagra or kamagra his heart had to be shocked back to life in the ambulance.His near-death experience forced Capalbo to radically change his diet.

He gave up red meat, bacon, and greasy sausage pizzas. He said goodbye to one viagra or kamagra of his favorite guilty pleasures. Garlic parmesan chicken wings. He quit all other fried foods.Capalbo is one of 18 million Americans who viagra or kamagra have coronary artery disease (CAD).

It happens when sticky plaque clogs your arteries and slows or blocks the flow of blood to and from the heart. With his favorite foods banished, Capalbo had to get creative viagra or kamagra in the kitchen. He learned how to prepare healthy dishes faster than a meal delivery. He still enjoys pizza, but now it’s homemade with a cauliflower crust -- viagra or kamagra and no cheese.

The grill has become a key appliance.When you have CAD, a heart-healthy diet -- low in saturated fats and processed foods and high in fresh produce and whole grains -- is an important part of your treatment.But changing your eating habits, and convincing loved ones to go along, isn’t always easy, says Sandra Arévalo, a registered dietitian in Nyack, NY, and a spokesperson for the Academy of Nutrition and Dietetics.“A lot of people are very traditional with their meals, and they don’t want to make any changes,” she says. €œAnd that’s viagra or kamagra the biggest barrier. You have to be willing to try new things.”A Dietitian’s TipsArévalo encourages culinary experiments. Whole-wheat pasta or brown rice viagra or kamagra can bring different textures and taste, compared to their white counterparts.“It’s like a taste shock,” she says of trying new foods.

But with each bite, it “opens your mind a little bit to know that it’s something new that you’re going to taste.” Shifting your food tastes may take as many as 30 attempts, Arévalo says. €œTaste buds get what we call educated,” she says viagra or kamagra. €œBy tasting a little every viagra or kamagra time, that’s how you change your taste buds.”Arévalo, who speaks Spanish, often works with Hispanic families. A common challenge is that their diet can be heavy on starchy foods, which can drive up your triglycerides -- a type of fat in your bloodstream.

Similarly, white rice, a staple in Asian cuisines, raises your blood sugar levels faster than whole grains like brown rice do.“I have tons of families that, because it’s in the culture, eat too many starchy foods viagra or kamagra at the same time,” Arévalo says of her Hispanic clients. €œIt’s not hard to find pasta, rice, and potatoes at one meal.”Try to limit your starchy foods to one per meal at most. If you have tacos for dinner, skip the side of rice -- the starch can come from the viagra or kamagra taco shells. Skip the sour cream, Arévalo says, and retire the refried beans.

Instead, boil beans until they are soft, then mash them to get the same texture.A Foodie’s Cooking HacksMike Carroll Jr., who played football through high school and into college, packed on viagra or kamagra the pounds after he left the gridiron and worked a desk job as a graphic designer. At his heaviest, he weighed more than 400 pounds.The 52-year-old, who has coronary artery disease and heart failure, has already lost more than 100 pounds. In late 2021, viagra or kamagra he weighed around 300. Carroll, who lives in Wichita, KS, plans to shed 25 more pounds to get on a heart transplant list.Like Capalbo, he’s a big fan of pasta.

His current favorite viagra or kamagra. Kelp noodles. For rice, he prefers viagra or kamagra cauliflower rice. He’s swapped mashed potatoes with mashed cauliflower from the frozen food aisle.Carroll, who describes himself as a “foodie,” sometimes posts his meals on social media.

He’s become a whiz viagra or kamagra with his air fryer, as he prefers crispy foods -- the crispier the better. With the air fryer, he can eat everything from chicken wings to turkey bacon without using oil.If he cooks bacon, Carroll may use it to build a BLT, wrapping the bacon, lettuce, and tomato inside a low-carb tortilla instead of bread. Or he may air-fry some wings and pair them with vegetable noodles and corn kernels on the viagra or kamagra side. The noodles, made of zucchini, carry a similar texture to pasta after you boil them a bit, he says.New Eating HabitsCapalbo, who is viagra or kamagra “100% Italian,” has tried pasta made with chickpeas and black beans since his 2020 heart attack.

His current preferred carb is brown rice pasta.Capalbo now mostly cooks at home and dines out only now and then. He loves salmon and often orders it, as well as making it viagra or kamagra at home. He avoids cream sauces in restaurants and suspects there’s hidden butter and other ingredients that make restaurant fish taste so good. €œIt’s the glazes and the seasonings, you don’t know what they are using,” he says.Going cold turkey on his former eating habits hasn’t been easy, Capalbo viagra or kamagra admits.

€œI used to get bacon on everything, I mean everything,” he says. €œIf I fantasize viagra or kamagra about anything, it’s a bacon cheeseburger.”But his bloodwork shows that healthier eating pays off. Within 5 months of starting his new way of life, Capalbo’s total cholesterol dropped from 195 to 105 and his triglycerides plummeted from 265 to 80. While cholesterol is only one part of heart risk, viagra or kamagra the goal is to keep total cholesterol under 200 and triglycerides under 150.

Capalbo’s cardiologist told him that had he been at home alone when he had his heart attack, “I would have been dead.” When Capalbo woke up in the intensive care unit, it was his teenage daughter who motivated him to overhaul his habits. Along with his new diet, he quit smoking and viagra or kamagra started walking almost every day.Capalbo’s daughter has since started college, and he plans to walk her down the aisle on her wedding one day. He hopes that other people with CAD will learn from his health scare.“I tell everybody. €˜Don’t be viagra or kamagra me.

Be better than me,’” he says. €œI literally viagra or kamagra had to die to figure it out.”Nov. 19, 2021 — Cases of the flu, that once annual viral intruder that was regularly the country’s worst annual health crisis, is showing signs of waking up again this fall.But, experts say, it is far too early to say if the country will have a normal – i.e., bad – flu season or a repeat of last year, when the flu all but disappeared amid the erectile dysfunction treatment kamagra. This flu viagra or kamagra season is starting out more like the seasons before the kamagra.

About 2% of all visits to doctors and outpatient clinics through viagra or kamagra Nov. 13 were flu or flu-like illnesses, compared to about 1.4% a year ago, the CDC says. Cases so far are being counted in the viagra or kamagra hundreds – 702 through Nov. 13.Still, while cases are low, they are increasing, the agency says.

The spread of viagra or kamagra flu is already high in New Mexico and moderate in Georgia. The rest of the country is seeing little activity, according to the CDC. This time last year, cases of flu, hospitalizations and deaths were down dramatically, despite fears that a drastic ''twindemic" could occur if cases of erectile dysfunction treatment and viagra or kamagra influenza increased greatly, and in tandem. The comparisons of last year's flu season statistics to previous years are startling — in a good way.In the 2019-2020 season, more 22,000 people in the U.S.

Died from viagra or kamagra flu. Last year, deaths decreased to about 700 for the 2020-2021 season.So, what might happen this year?. Will flu be a no-show viagra or kamagra once again?. Several top experts say it’s complicated.

"It's a hot question and I'd viagra or kamagra love to give you a concrete answer. But everyone is having trouble predicting." -- Stuart Ray, MD, professor of medicine and infectious disease specialist at Johns Hopkins Medicine in Baltimore."It's very hard to predict exactly where the flu season will land. What seems to be the case is that it will be worse than last year, but it's unclear whether or not it will be an ordinary flu season." -- Amesh Adalja, MD, senior scholar at the Johns Hopkins Center for Health Security."There will be flu, but I can't tell you how bad it will be." We do know that flu will be back." -- William Schaffner, MD, infectious disease specialist and professor of preventive viagra or kamagra medicine at Vanderbilt University Medical Center in Nashville. Already, Schaffner says, “we are beginning to hear about some outbreaks."One outbreak triggering concern is at the University of Michigan, Ann Arbor, where 528 flu cases have been diagnosed at the University Health Service since Oct.

6. The CDC sent a team to investigate the outbreak. Florida A&M University and Florida State University have also seen large outbreaks this month.Outbreaks on college campuses are not surprising, Schaffner said. "That’s a population that is under-vaccinated," he says, and students are often in close quarters with many others.

University of Michigan officials said 77% of the cases are in unvaccinated people."Predictions about this year's flu season also have to take into account that mask wearing and social distancing that were common last year, but have become less common or sometimes nonexistent this year.Despite uncertainty about how this year's flu season will play out, several changes and advances in play for this year's flu season are aimed at keeping illness low.The composition of the treatments has been updated — and each treatment targets four kamagraes expected to circulate.The flu treatment and the erectile dysfunction treatments can be given at the same time.The CDC has updated guidance for timing of the flu treatment for some people.A new dashboard is tracking flu vaccination rates nationwide, and the CDC has an education campaign, fearing the importance of the flu treatment has taken a back seat with the attention largely on erectile dysfunction treatment and its treatment since the kamagra began. What's in This Year's treatment?. This year, all the flu treatments in the U.S. Are four component (quadrivalent) shots, meant to protect against the four flu kamagraes most likely to spread and cause sickness this season.The FDA's treatments and Related Biological Product Advisory Committee (VRBPAC) selects the specific kamagraes that each year's treatment should target.

To select, they take into account surveillance data with details about recent influenza cultures, responses to the previous year's treatments and other information.Both the egg-based treatments and the cell- or recombinant-based treatments will target two influenza A strains and two influenza B strains. Options include injections or a nasal spray. Several of the formulas are approved for use in those age 65 and up, including a high-dose treatment and the adjuvanted flu treatment. The aim of each is to create a stronger immune response, as people's immune systems weaken with age.

However, the CDC cautions people not to put off the vaccination while waiting for the high-dose or adjuvanted. Getting the treatment that's available is the best thing to do, experts say. treatment TimingIn general, September and October were good times for flu vaccinations, the CDC says. While it's ideal to be vaccinated by the end of October, it still recommends vaccinating later than that rather than skipping it.Even if you are unvaccinated in December or January, it's still a good idea to get it then, Schaffner agrees.

You would still get some protection, he says, since ''for the most part in the U.S., flu peaks in February." But he stresses that earlier is better.While children can get vaccinated as soon as doses are available — even July or August — adults, especially if 65 and older, because of their weakened immune systems, should generally not get vaccinated that early. That's because protection will decrease over time and they may not be protected for the entire flu season. But, early is better than not at all, the CDC says. Some children ages 6 months to 8 years may need two doses of flu treatment.

Those getting vaccinated for the first time need two doses (spaced 4 weeks apart). Others in this age group who only got one dose previously need to get 2 doses this season. Early vaccination can also be considered for women in the third trimester of pregnancy, because the immunization can help provide protection to their infants after birth. Infants can't be vaccinated until age 6 months.

Two Arms, Two treatmentsWith millions of Americans now lining up for their erectile dysfunction treatment boosters, experts urge them to get the flu treatment at the same time. It's acceptable to get both treatments the same day, experts agree."You can [even] do 2 in one arm, spaced by an inch," says L.J. Tan, PhD, chief policy and partnership officer, Immunization Action Coalition, an organization devoted to increasing immunization rates. "We co-administer treatments to kids all the time." And, Tan says, ''the flu treatment is not going to amplify any reaction you would have to the erectile dysfunction treatment."Tracking VaccinationsAccording to the CDC National Flu Vaccination Dashboard, about 162 million doses of flu treatment have been distributed as of Nov.

5.It expects about 58.5% of the population to get a flu shot this season, up from about 54.8% last season. Undoing the ‘Flu Isn't Bad’ Thinking One common misconception, especially from parents, is that ''the flu is not bad, it doesn't cause serious problems," says Flor M. Munoz, MD, MSc, medical director of transplant infectious diseases at Texas Children's Hospital in Houston."Flu by itself can be serious," she says. And now, with erectile dysfunction treatment, she says, ''we do worry.

If someone got both s, they could get quite sick."Among the potential complications in kids, especially those under 5 years, are pneumonia, dehydration, brain dysfunction and sinus and ear s.The treatment for flu, like for erectile dysfunction treatment, isn't perfect, she also tells parents. "In a good year, it gives 60 to 70% protection. " But it can be much less protective than that, too. Even so, "if you get vaccinated and still get the flu, you will have milder illness."Anti-Virals to the RescueWhen flu symptoms — fever, cough, sore throat, runny nose, body aches, headaches, chills and fatigue — appear, anti-viral treatments can lessen the time you are sick by about a day, according to the CDC.

They are available only by prescription and work best when started within 2 days of becoming sick with flu. Four antiviral drugs to treat flu are FDA-approved, including:Oseltamivir phosphate (generic or as Tamiflu)Zanamivir (Relenza)Peramivir (Rapivab)Baloxavir marboxil (Xofluza)Depending on the drug and method of administration, the drugs are given for 1 to 5 days, generally, but sometimes longer than 5 days.Track Local Flu RatesRay of Johns Hopkins suggests keeping an eye on how widespread flu is in your community, just as we've gotten used to tracking erectile dysfunction treatment rates, and then taking precautions such as masking up and social distancing. "Maybe we are a little more nimble now in responding to risk," he says, given the practice gotten with erectile dysfunction treatment.He says adapting these habits in responding to flu outbreaks would be helpful—and more natural for most people than in the past. ''I don’t think it was usual ever, 3 years ago, to see people out in masks when flu rates were high."Nov.

19, 2021 -- President Joe Biden is in “good spirits” following his trip to Walter Reed hospital today for his first annual physical exam and routine colonoscopy as commander-in-chief, according to White House Press Secretary Jen Psaki.A colonoscopy is a medical procedure where doctors examine your large intestine (colon) and your rectum.A flexible tube with a small camera at the tip is inserted inside your rectum, so that doctors can check for signs of colon cancer, bleeding, or any other abnormalities.Because Biden went under anesthesia -- a treatment that makes you sleepy and prevents you from feeling pain -- he temporarily transferred presidential power to Vice President Kamala Harris, making her the first woman in U.S. History to serve as acting president, though only for around 90 minutes.The 25th amendment to theConstitution allows for this transfer of power when a president is unable to fulfill their duties. These powers are then shifted to the vice president, until the president documents in writing that he can, once again, fully resume his role. Biden, who turns 79 tomorrow, is the oldest president in U.S.

History.His health has been a hot topic of conversation since he announced he was running for office.In 2019, Kevin O’Connor, DO, the White House physician and Biden’s personal doctor for over a decade, released a document with details on Biden’s health.The report said that Biden had been taking the drug Eliquis to help prevent blood clots, Crestor to lower his triglycerides and cholesterol, Nexium for acid reflux, Allegra for allergies, and a nasal spray.The document also stated that the president had been receiving treatment for atrial fibrillation, or an irregular heartbeat. But O’Conner said overall, then-presidential candidate Biden was “a healthy, vigorous, 77-year-old male, who is fit to successfully execute the duties of the Presidency.”Biden has had serious health scares in the past, including a brain aneurysm when he served as a U.S. Senator in 1988.Other procedures in Biden’s medical history include gall bladder removal in 2003, various surgeries for bone injuries, and the removal on nonmelanoma skin cancers.Biden is still scheduled to attend the annual White House turkey pardoning ceremony in the Rose Garden today.By Robert Preidt and Ernie Mundell HealthDay ReportersTHURSDAY, Nov. 19, 2021 (HealthDay News) – People who live with chronic migraines suffer intense throbbing and pulsing, sensitivity to light and sound, nausea and vomiting.

Could a plant-based diet, credited with a variety of positive health impacts, also help ease these chronic symptoms?. It might. Researchers in New York have published a case study of one man with severe chronic migraines who had tried everything to curb them, and then switched to a plant-based diet -- loaded with a lot of dark green leafy vegetables. He quickly found significant relief from the headaches, doctors reported online Nov.

18 in the journal BMJ Case Reports."This report suggests that a whole food plant-based diet may offer a safe, effective and permanent treatment for reversing chronic migraine," wrote a team led by Dr. David Dunaief, who specializes in nutritional medicine and has a private practice in East Setauket, N.Y.One expert in migraine who wasn't connected to the study was cautiously optimistic about the findings. "It is hard to make much from one case report, [but] it does illustrate the importance of all of these non-pharmacological, evidence-based treatments," said Dr. Noah Rosen.

He directs Northwell Health's Headache Center in Great Neck, N.Y.As the researchers noted, more than 1 billion people worldwide have migraines, defined as one-side, pulsating headaches, sometimes with a variety of other symptoms, that last between four and 72 hours. Some migraines are episodic, meaning they happen fewer than 15 days per month. Others are chronic, with 15 or more migraine days per month plus migraine features on eight days per month. To be considered successful, migraine treatment must cut the frequency and length of the attacks in half or improve symptoms.

The 60-year-old man whose experiences are detailed in the report had endured severe migraine headaches without aura for more than 12 years. Six months before his clinic referral, his migraines had become chronic, occurring anywhere from 18 to 24 days each month.He had tried a number of potential fixes, including the prescribed medications zolmitriptan and topiramate. He also cut out potential 'trigger' foods, including chocolate, cheese, nuts, caffeine, and dried fruit. Beyond this, the man also tried yoga and meditation to curb the attacks.

None of those interventions had worked.The man described the pain as throbbing, starting suddenly and intensely in the forehead and temple on the left side of his head. His migraines usually lasted 72 hours and also included sensitivity to light and sound, nausea and vomiting. His pain severity was 10 to 12 out of a scale of 10.He didn't have high levels of systemic inflammation but had a normal level of beta carotene in his blood, possibly because he ate sweet potatoes daily. Sweet potatoes are relatively low in food nutrients known as carotenoids, which carry anti-inflammatory and antioxidant properties, the authors explained.

Leafy greens such as spinach, kale and watercress do contain high levels of carotenoids, however.So, Rosen's team advised the man to adopt the Low Inflammatory Foods Everyday (LIFE) diet. It's a nutrient-dense, whole food, plant-based diet. The regimen advocates eating at least five ounces by weight of raw or cooked dark green leafy vegetables every day, drinking one 32-ounce daily green LIFE smoothie, and limiting intake of whole grains, starchy vegetables, oils, and animal protein, particularly dairy and red meat.After two months on the diet, the man said his migraines had been dramatically reduced -- to just one migraine day per month, and even that headache was less severe. At the same time, his blood tests showed a substantial rise in beta-carotene levels.

Soon, the man stopped taking all his migraine meds. His migraines stopped completely after three months and haven't returned in 7 1/2 years.The man was allergic, and previously published research suggests that better control of allergies may also lead to fewer migraine headaches. In this case, the man's allergy symptoms also improved -- to the point that he no longer needed to use seasonal medication.He was also HIV-positive, and HIV has been linked to a heightened risk of migraines. It is possible that the man's HIV status and antiretroviral drugs had contributed to his symptoms, the authors said, though it wasn't possible to study this further without stopping the antiretroviral treatment."While this report describes one very adherent patient who had a remarkable response, the LIFE diet has reduced migraine frequency within 3 months in several additional patients," Dunaief added.

For his part, Rosen said that "the role of proper diet and migraine has had a few studies demonstrating benefit." Being properly hydrated, eating a healthy "low-glycemic" diet and getting lots of omega 3 fatty acids (such as are found in oily fish) have all been shown to have a positive effect on curbing migraines, he said. Beyond food, getting good sleep, regular exercise and psychological interventions such as "cognitive behavioral therapy, mindfulness and progressive muscle relaxation" may also help, Rosen said.More informationFind out more about migraines at the American Migraine Foundation.SOURCE. BMJ Case reports, news release, Nov. 18, 2021Researchers remain hopeful that they're heading in the right direction to finding a cure for HIV, the kamagra that causes AIDS.

Right now, it’s still out of reach. But the unusual cases of four people may hold clues.The latest case is a 30-year-old woman in Argentina whose name hasn’t been made public. She had HIV, but for 8 years, it has been “undetectable” in her body, though she didn’t take antiretroviral medication, researchers reported in the Annals of Internal Medicine in November 2021. Scientists don’t know exactly how that works and can’t say for sure that she is cured.

But they wrote in the study that cases like the Argentinian woman’s may be “extremely rare but possible.”Perhaps the best known is the “Berlin patient,” Timothy Ray Brown. He’s the first person ever to be cured of HIV. Brown found out in 2006 that he had acute myeloid leukemia. He already knew he had HIV and had been taking medicine for it for years.After chemotherapy didn’t help his leukemia, Brown went to Berlin, where he got two bone marrow transplants from an HIV-resistant donor.

Ten years later, Brown is leukemia- and HIV-free. Other HIV-positive leukemia patients who got similar treatments haven’t been free of HIV. Experts still don’t know why Brown became free of HIV. Clues From BabiesUsually, infants who are born to HIV-positive mothers get medications to prevent the becoming infected themselves.

Only after two tests come back showing HIV do doctors switch to drugs that treat HIV. The first test isn't recommended until the baby is 2-3 weeks old. Sometimes doctors take a different approach. A baby from California born to a mother with AIDS got the treatment medicines, called antiretroviral therapy (ART), when she was only 4 hours old.

At 9 months, back in 2014, she was still HIV-negative -- and was still getting ART.Another case also made headlines. Doctors gave a baby from Mississippi treatment medications just 30 hours after she was born to a woman who had HIV. The little girl tested HIV-free for more than 2 years, and some people said she was “in remission” at the time, which was in 2013. But in 2014, at age 4, HIV turned up in the Mississippi baby’s blood.

Her mother had stopped giving her ART when she was 18 months old, against medical advice. The “Mississippi baby, "whose name hasn’t been made public, went back on ART. She finished kindergarten in June 2016 and is “doing great,” Hannah Gay, MD, who treated the baby at the University of Mississippi Medical Center, says in a news release.Gay says she’s making a scrapbook for the little girl so she can one day know more about the role she played in helping experts better understand HIV.HIV Hides in the BodyScientists had hoped giving strong treatment medications so soon after birth would get rid of the kamagra or prevent it from spreading and doing damage.The fact that the HIV kamagra eventually turned up in the “Mississippi baby” isn't unexpected, says Robert Siliciano, MD, PhD, professor of medicine in the infectious diseases department at Johns Hopkins University School of Medicine. It supports the theory that HIV cells stay in the body, just out of view in a hidden "reservoir.""Curing HIV is going to require strategies to eliminate this reservoir," he says.Start Treatment EarlierPeople who have HIV should start treatment as soon as they know.

That's easier to do for babies, who can be tested and retested right after they're born. Adults rarely know exactly when they're infected.If you're at risk, getting tested for HIV more often may lead to earlier, more effective treatment. Studies have found that those who adhere to their treatment and maintain a healthy lifestyle can not only live longer, but have virtually the same life expectancy as someone who is not infected.When someone tests positive in a clinic, for example, it might make sense for a doctor there to "start treatment and ask questions later," says David Hardy, MD, a board member of the HIV Medicine Association. Still, patients will need to understand their diagnosis and the treatment and be willing to commit to what is currently a life-long treatment.And until there are better tests to find the kamagra hiding in the body, doctors can't accurately call anyone "HIV-free.".

Michael Capalbo used to subsist mostly on meals in restaurants and takeouts.“I just thought Can i buy propecia over the counter uk I was immortal,” says the 54-year-old generic kamagra online Connecticut salesman. €œI was literally living on burgers and wings and pizza and stuff like that.”Then in April of 2020, while at work at Walgreens, Capalbo had a massive heart attack caused by generic kamagra online a complete blockage in a major artery. A pharmacist gave him an aspirin and called 911. Capalbo later learned that his heart generic kamagra online had to be shocked back to life in the ambulance.His near-death experience forced Capalbo to radically change his diet. He gave up red meat, bacon, and greasy sausage pizzas.

He said goodbye to one of generic kamagra online his favorite guilty pleasures. Garlic parmesan chicken wings. He quit all other fried foods.Capalbo is one of 18 million Americans who have generic kamagra online coronary artery disease (CAD). It happens when sticky plaque clogs your arteries and slows or blocks the flow of blood to and from the heart. With his favorite foods banished, Capalbo had to get creative in generic kamagra online the kitchen.

He learned how to prepare healthy dishes faster than a meal delivery. He still enjoys pizza, generic kamagra online but now it’s homemade with a cauliflower crust -- and no cheese. The grill has become a key appliance.When you have CAD, a heart-healthy diet -- low in saturated fats and processed foods and high in fresh produce and whole grains -- is an important part of your treatment.But changing your eating habits, and convincing loved ones to go along, isn’t always easy, says Sandra Arévalo, a registered dietitian in Nyack, NY, and a spokesperson for the Academy of Nutrition and Dietetics.“A lot of people are very traditional with their meals, and they don’t want to make any changes,” she says. €œAnd that’s generic kamagra online the biggest barrier. You have to be willing to try new things.”A Dietitian’s TipsArévalo encourages culinary experiments.

Whole-wheat pasta or brown rice can bring different textures and taste, compared to their white counterparts.“It’s like a taste generic kamagra online shock,” she says of trying new foods. But with each bite, it “opens your mind a little bit to know that it’s something new that you’re going to taste.” Shifting your food tastes may take as many as 30 attempts, Arévalo says. €œTaste buds generic kamagra online get what we call educated,” she says. €œBy tasting a little every time, that’s how you change your taste buds.”Arévalo, who speaks Spanish, often generic kamagra online works with Hispanic families. A common challenge is that their diet can be heavy on starchy foods, which can drive up your triglycerides -- a type of fat in your bloodstream.

Similarly, white rice, a staple in Asian cuisines, generic kamagra online raises your blood sugar levels faster than whole grains like brown rice do.“I have tons of families that, because it’s in the culture, eat too many starchy foods at the same time,” Arévalo says of her Hispanic clients. €œIt’s not hard to find pasta, rice, and potatoes at one meal.”Try to limit your starchy foods to one per meal at most. If you have tacos for dinner, skip the generic kamagra online side of rice -- the starch can come from the taco shells. Skip the sour cream, Arévalo says, and retire the refried beans. Instead, boil beans until they are soft, then mash them to get the generic kamagra online same texture.A Foodie’s Cooking HacksMike Carroll Jr., who played football through high school and into college, packed on the pounds after he left the gridiron and worked a desk job as a graphic designer.

At his heaviest, he weighed more than 400 pounds.The 52-year-old, who has coronary artery disease and heart failure, has already lost more than 100 pounds. In late generic kamagra online 2021, he weighed around 300. Carroll, who lives in Wichita, KS, plans to shed 25 more pounds to get on a heart transplant list.Like Capalbo, he’s a big fan of pasta. His current favorite generic kamagra online. Kelp noodles.

For rice, he generic kamagra online prefers cauliflower rice. He’s swapped mashed potatoes with mashed cauliflower from the frozen food aisle.Carroll, who describes himself as a “foodie,” sometimes posts his meals on social media. He’s become a whiz generic kamagra online with his air fryer, as he prefers crispy foods -- the crispier the better. With the air fryer, he can eat everything from chicken wings to turkey bacon without using oil.If he cooks bacon, Carroll may use it to build a BLT, wrapping the bacon, lettuce, and tomato inside a low-carb tortilla instead of bread. Or he generic kamagra online may air-fry some wings and pair them with vegetable noodles and corn kernels on the side.

The noodles, made of zucchini, carry a similar texture to pasta after you boil them a generic kamagra online bit, he says.New Eating HabitsCapalbo, who is “100% Italian,” has tried pasta made with chickpeas and black beans since his 2020 heart attack. His current preferred carb is brown rice pasta.Capalbo now mostly cooks at home and dines out only now and then. He loves generic kamagra online salmon and often orders it, as well as making it at home. He avoids cream sauces in restaurants and suspects there’s hidden butter and other ingredients that make restaurant fish taste so good. €œIt’s the glazes and the seasonings, you don’t know what they are using,” he says.Going cold turkey on his generic kamagra online former eating habits hasn’t been easy, Capalbo admits.

€œI used to get bacon on everything, I mean everything,” he says. €œIf I fantasize about anything, generic kamagra online it’s a bacon cheeseburger.”But his bloodwork shows that healthier eating pays off. Within 5 months of starting his new way of life, Capalbo’s total cholesterol dropped from 195 to 105 and his triglycerides plummeted from 265 to 80. While cholesterol is only one part of heart risk, the goal is to keep total cholesterol under 200 and triglycerides generic kamagra online under 150. Capalbo’s cardiologist told him that had he been at home alone when he had his heart attack, “I would have been dead.” When Capalbo woke up in the intensive care unit, it was his teenage daughter who motivated him to overhaul his habits.

Along with his new diet, he quit smoking and started walking almost generic kamagra online every day.Capalbo’s daughter has since started college, and he plans to walk her down the aisle on her wedding one day. He hopes that other people with CAD will learn from his health scare.“I tell everybody. €˜Don’t be me generic kamagra online. Be better than me,’” he says. €œI literally generic kamagra online had to die to figure it out.”Nov.

19, 2021 — Cases of the flu, that once annual viral intruder that was regularly the country’s worst annual health crisis, is showing signs of waking up again this fall.But, experts say, it is far too early to say if the country will have a normal – i.e., bad – flu season or a repeat of last year, when the flu all but disappeared amid the erectile dysfunction treatment kamagra. This flu generic kamagra online season is starting out more like the seasons before the kamagra. About 2% of all visits generic kamagra online to doctors and outpatient clinics through Nov. 13 were flu or flu-like illnesses, compared to about 1.4% a year ago, the CDC says. Cases so far are being counted generic kamagra online in the hundreds – 702 through Nov.

13.Still, while cases are low, they are increasing, the agency says. The spread of flu is already generic kamagra online high in New Mexico and moderate in Georgia. The rest of the country is seeing little activity, according to the CDC. This time last year, cases of flu, hospitalizations and deaths were down dramatically, despite fears that a drastic ''twindemic" could occur if cases of erectile dysfunction treatment and influenza increased generic kamagra online greatly, and in tandem. The comparisons of last year's flu season statistics to previous years are startling — in a good way.In the 2019-2020 season, more 22,000 people in the U.S.

Died from generic kamagra online flu. Last year, deaths decreased to about 700 for the 2020-2021 season.So, what might happen this year?. Will flu be generic kamagra online a no-show once again?. Several top experts say it’s complicated. "It's a hot question generic kamagra online and I'd love to give you a concrete answer.

But everyone is having trouble predicting." -- Stuart Ray, MD, professor of medicine and infectious disease specialist at Johns Hopkins Medicine in Baltimore."It's very hard to predict exactly where the flu season will land. What seems to be the case is that it will be worse than last year, but it's unclear whether or not it will be an ordinary flu season." -- Amesh Adalja, MD, senior scholar at the generic kamagra online Johns Hopkins Center for Health Security."There will be flu, but I can't tell you how bad it will be." We do know that flu will be back." -- William Schaffner, MD, infectious disease specialist and professor of preventive medicine at Vanderbilt University Medical Center in Nashville. Already, Schaffner says, “we are beginning to hear about some outbreaks."One outbreak triggering concern is at the University of Michigan, Ann Arbor, where 528 flu cases have been diagnosed at the University Health Service since Oct. 6. The CDC sent a team to investigate the outbreak.

Florida A&M University and Florida State University have also seen large outbreaks this month.Outbreaks on college campuses are not surprising, Schaffner said. "That’s a population that is under-vaccinated," he says, and students are often in close quarters with many others. University of Michigan officials said 77% of the cases are in unvaccinated people."Predictions about this year's flu season also have to take into account that mask wearing and social distancing that were common last year, but have become less common or sometimes nonexistent this year.Despite uncertainty about how this year's flu season will play out, several changes and advances in play for this year's flu season are aimed at keeping illness low.The composition of the treatments has been updated — and each treatment targets four kamagraes expected to circulate.The flu treatment and the erectile dysfunction treatments can be given at the same time.The CDC has updated guidance for timing of the flu treatment for some people.A new dashboard is tracking flu vaccination rates nationwide, and the CDC has an education campaign, fearing the importance of the flu treatment has taken a back seat with the attention largely on erectile dysfunction treatment and its treatment since the kamagra began. What's in This Year's treatment?. This year, all the flu treatments in the U.S.

Are four component (quadrivalent) shots, meant to protect against the four flu kamagraes most likely to spread and cause sickness this season.The FDA's treatments and Related Biological Product Advisory Committee (VRBPAC) selects the specific kamagraes that each year's treatment should target. To select, they take into account surveillance data with details about recent influenza cultures, responses to the previous year's treatments and other information.Both the egg-based treatments and the cell- or recombinant-based treatments will target two influenza A strains and two influenza B strains. Options include injections or a nasal spray. Several of the formulas are approved for use in those age 65 and up, including a high-dose treatment and the adjuvanted flu treatment. The aim of each is to create a stronger immune response, as people's immune systems weaken with age.

However, the CDC cautions people not to put off the vaccination while waiting for the high-dose or adjuvanted. Getting the treatment that's available is the best thing to do, experts say. treatment TimingIn general, September and October were good times for flu vaccinations, the CDC says. While it's ideal to be vaccinated by the end of October, it still recommends vaccinating later than that rather than skipping it.Even if you are unvaccinated in December or January, it's still a good idea to get it then, Schaffner agrees. You would still get some protection, he says, since ''for the most part in the U.S., flu peaks in February." But he stresses that earlier is better.While children can get vaccinated as soon as doses are available — even July or August — adults, especially if 65 and older, because of their weakened immune systems, should generally not get vaccinated that early.

That's because protection will decrease over time and they may not be protected for the entire flu season. But, early is better than not at all, the CDC says. Some children ages 6 months to 8 years may need two doses of flu treatment. Those getting vaccinated for the first time need two doses (spaced 4 weeks apart). Others in this age group who only got one dose previously need to get 2 doses this season.

Early vaccination can also be considered for women in the third trimester of pregnancy, because the immunization can help provide protection to their infants after birth. Infants can't be vaccinated until age 6 months. Two Arms, Two treatmentsWith millions of Americans now lining up for their erectile dysfunction treatment boosters, experts urge them to get the flu treatment at the same time. It's acceptable to get both treatments the same day, experts agree."You can [even] do 2 in one arm, spaced by an inch," says L.J. Tan, PhD, chief policy and partnership officer, Immunization Action Coalition, an organization devoted to increasing immunization rates.

"We co-administer treatments to kids all the time." And, Tan says, ''the flu treatment is not going to amplify any reaction you would have to the erectile dysfunction treatment."Tracking VaccinationsAccording to the CDC National Flu Vaccination Dashboard, about 162 million doses of flu treatment have been distributed as of Nov. 5.It expects about 58.5% of the population to get a flu shot this season, up from about 54.8% last season. Undoing the ‘Flu Isn't Bad’ Thinking One common misconception, especially from parents, is that ''the flu is not bad, it doesn't cause serious problems," says Flor M. Munoz, MD, MSc, medical director of transplant infectious diseases at Texas Children's Hospital in Houston."Flu by itself can be serious," she says. And now, with erectile dysfunction treatment, she says, ''we do worry.

If someone got both s, they could get quite sick."Among the potential complications in kids, especially those under 5 years, are pneumonia, dehydration, brain dysfunction and sinus and ear s.The treatment for flu, like for erectile dysfunction treatment, isn't perfect, she also tells parents. "In a good year, it gives 60 to 70% protection. " But it can be much less protective than that, too. Even so, "if you get vaccinated and still get the flu, you will have milder illness."Anti-Virals to the RescueWhen flu symptoms — fever, cough, sore throat, runny nose, body aches, headaches, chills and fatigue — appear, anti-viral treatments can lessen the time you are sick by about a day, according to the CDC. They are available only by prescription and work best when started within 2 days of becoming sick with flu.

Four antiviral drugs to treat flu are FDA-approved, including:Oseltamivir phosphate (generic or as Tamiflu)Zanamivir (Relenza)Peramivir (Rapivab)Baloxavir marboxil (Xofluza)Depending on the drug and method of administration, the drugs are given for 1 to 5 days, generally, but sometimes longer than 5 days.Track Local Flu RatesRay of Johns Hopkins suggests keeping an eye on how widespread flu is in your community, just as we've gotten used to tracking erectile dysfunction treatment rates, and then taking precautions such as masking up and social distancing. "Maybe we are a little more nimble now in responding to risk," he says, given the practice gotten with erectile dysfunction treatment.He says adapting these habits in responding to flu outbreaks would be helpful—and more natural for most people than in the past. ''I don’t think it was usual ever, 3 years ago, to see people out in masks when flu rates were high."Nov. 19, 2021 -- President Joe Biden is in “good spirits” following his trip to Walter Reed hospital today for his first annual physical exam and routine colonoscopy as commander-in-chief, according to White House Press Secretary Jen Psaki.A colonoscopy is a medical procedure where doctors examine your large intestine (colon) and your rectum.A flexible tube with a small camera at the tip is inserted inside your rectum, so that doctors can check for signs of colon cancer, bleeding, or any other abnormalities.Because Biden went under anesthesia -- a treatment that makes you sleepy and prevents you from feeling pain -- he temporarily transferred presidential power to Vice President Kamala Harris, making her the first woman in U.S. History to serve as acting president, though only for around 90 minutes.The 25th amendment to theConstitution allows for this transfer of power when a president is unable to fulfill their duties.

These powers are then shifted to the vice president, until the president documents in writing that he can, once again, fully resume his role. Biden, who turns 79 tomorrow, is the oldest president in U.S. History.His health has been a hot topic of conversation since he announced he was running for office.In 2019, Kevin O’Connor, DO, the White House physician and Biden’s personal doctor for over a decade, released a document with details on Biden’s health.The report said that Biden had been taking the drug Eliquis to help prevent blood clots, Crestor to lower his triglycerides and cholesterol, Nexium for acid reflux, Allegra for allergies, and a nasal spray.The document also stated that the president had been receiving treatment for atrial fibrillation, or an irregular heartbeat. But O’Conner said overall, then-presidential candidate Biden was “a healthy, vigorous, 77-year-old male, who is fit to successfully execute the duties of the Presidency.”Biden has had serious health scares in the past, including a brain aneurysm when he served as a U.S. Senator in 1988.Other procedures in Biden’s medical history include gall bladder removal in 2003, various surgeries for bone injuries, and the removal on nonmelanoma skin cancers.Biden is still scheduled to attend the annual White House turkey pardoning ceremony in the Rose Garden today.By Robert Preidt and Ernie Mundell HealthDay ReportersTHURSDAY, Nov.

19, 2021 (HealthDay News) – People who live with chronic migraines suffer intense throbbing and pulsing, sensitivity to light and sound, nausea and vomiting. Could a plant-based diet, credited with a variety of positive health impacts, also help ease these chronic symptoms?. It might. Researchers in New York have published a case study of one man with severe chronic migraines who had tried everything to curb them, and then switched to a plant-based diet -- loaded with a lot of dark green leafy vegetables. He quickly found significant relief from the headaches, doctors reported online Nov.

18 in the journal BMJ Case Reports."This report suggests that a whole food plant-based diet may offer a safe, effective and permanent treatment for reversing chronic migraine," wrote a team led by Dr. David Dunaief, who specializes in nutritional medicine and has a private practice in East Setauket, N.Y.One expert in migraine who wasn't connected to the study was cautiously optimistic about the findings. "It is hard to make much from one case report, [but] it does illustrate the importance of all of these non-pharmacological, evidence-based treatments," said Dr. Noah Rosen. He directs Northwell Health's Headache Center in Great Neck, N.Y.As the researchers noted, more than 1 billion people worldwide have migraines, defined as one-side, pulsating headaches, sometimes with a variety of other symptoms, that last between four and 72 hours.

Some migraines are episodic, meaning they happen fewer than 15 days per month. Others are chronic, with 15 or more migraine days per month plus migraine features on eight days per month. To be considered successful, migraine treatment must cut the frequency and length of the attacks in half or improve symptoms. The 60-year-old man whose experiences are detailed in the report had endured severe migraine headaches without aura for more than 12 years. Six months before his clinic referral, his migraines had become chronic, occurring anywhere from 18 to 24 days each month.He had tried a number of potential fixes, including the prescribed medications zolmitriptan and topiramate.

He also cut out potential 'trigger' foods, including chocolate, cheese, nuts, caffeine, and dried fruit. Beyond this, the man also tried yoga and meditation to curb the attacks. None of those interventions had worked.The man described the pain as throbbing, starting suddenly and intensely in the forehead and temple on the left side of his head. His migraines usually lasted 72 hours and also included sensitivity to light and sound, nausea and vomiting. His pain severity was 10 to 12 out of a scale of 10.He didn't have high levels of systemic inflammation but had a normal level of beta carotene in his blood, possibly because he ate sweet potatoes daily.

Sweet potatoes are relatively low in food nutrients known as carotenoids, which carry anti-inflammatory and antioxidant properties, the authors explained. Leafy greens such as spinach, kale and watercress do contain high levels of carotenoids, however.So, Rosen's team advised the man to adopt the Low Inflammatory Foods Everyday (LIFE) diet. It's a nutrient-dense, whole food, plant-based diet. The regimen advocates eating at least five ounces by weight of raw or cooked dark green leafy vegetables every day, drinking one 32-ounce daily green LIFE smoothie, and limiting intake of whole grains, starchy vegetables, oils, and animal protein, particularly dairy and red meat.After two months on the diet, the man said his migraines had been dramatically reduced -- to just one migraine day per month, and even that headache was less severe. At the same time, his blood tests showed a substantial rise in beta-carotene levels.

Soon, the man stopped taking all his migraine meds. His migraines stopped completely after three months and haven't returned in 7 1/2 years.The man was allergic, and previously published research suggests that better control of allergies may also lead to fewer migraine headaches. In this case, the man's allergy symptoms also improved -- to the point that he no longer needed to use seasonal medication.He was also HIV-positive, and HIV has been linked to a heightened risk of migraines. It is possible that the man's HIV status and antiretroviral drugs had contributed to his symptoms, the authors said, though it wasn't possible to study this further without stopping the antiretroviral treatment."While this report describes one very adherent patient who had a remarkable response, the LIFE diet has reduced migraine frequency within 3 months in several additional patients," Dunaief added. For his part, Rosen said that "the role of proper diet and migraine has had a few studies demonstrating benefit." Being properly hydrated, eating a healthy "low-glycemic" diet and getting lots of omega 3 fatty acids (such as are found in oily fish) have all been shown to have a positive effect on curbing migraines, he said.

Beyond food, getting good sleep, regular exercise and psychological interventions such as "cognitive behavioral therapy, mindfulness and progressive muscle relaxation" may also help, Rosen said.More informationFind out more about migraines at the American Migraine Foundation.SOURCE. BMJ Case reports, news release, Nov. 18, 2021Researchers remain hopeful that they're heading in the right direction to finding a cure for HIV, the kamagra that causes AIDS. Right now, it’s still out of reach. But the unusual cases of four people may hold clues.The latest case is a 30-year-old woman in Argentina whose name hasn’t been made public.

She had HIV, but for 8 years, it has been “undetectable” in her body, though she didn’t take antiretroviral medication, researchers reported in the Annals of Internal Medicine in November 2021. Scientists don’t know exactly how that works and can’t say for sure that she is cured. But they wrote in the study that cases like the Argentinian woman’s may be “extremely rare but possible.”Perhaps the best known is the “Berlin patient,” Timothy Ray Brown. He’s the first person ever to be cured of HIV. Brown found out in 2006 that he had acute myeloid leukemia.

He already knew he had HIV and had been taking medicine for it for years.After chemotherapy didn’t help his leukemia, Brown went to Berlin, where he got two bone marrow transplants from an HIV-resistant donor. Ten years later, Brown is leukemia- and HIV-free. Other HIV-positive leukemia patients who got similar treatments haven’t been free of HIV. Experts still don’t know why Brown became free of HIV. Clues From BabiesUsually, infants who are born to HIV-positive mothers get medications to prevent the becoming infected themselves.

Only after two tests come back showing HIV do doctors switch to drugs that treat HIV. The first test isn't recommended until the baby is 2-3 weeks old. Sometimes doctors take a different approach. A baby from California born to a mother with AIDS got the treatment medicines, called antiretroviral therapy (ART), when she was only 4 hours old. At 9 months, back in 2014, she was still HIV-negative -- and was still getting ART.Another case also made headlines.

Doctors gave a baby from Mississippi treatment medications just 30 hours after she was born to a woman who had HIV. The little girl tested HIV-free for more than 2 years, and some people said she was “in remission” at the time, which was in 2013. But in 2014, at age 4, HIV turned up in the Mississippi baby’s blood. Her mother had stopped giving her ART when she was 18 months old, against medical advice. The “Mississippi baby, "whose name hasn’t been made public, went back on ART.

She finished kindergarten in June 2016 and is “doing great,” Hannah Gay, MD, who treated the baby at the University of Mississippi Medical Center, says in a news release.Gay says she’s making a scrapbook for the little girl so she can one day know more about the role she played in helping experts better understand HIV.HIV Hides in the BodyScientists had hoped giving strong treatment medications so soon after birth would get rid of the kamagra or prevent it from spreading and doing damage.The fact that the HIV kamagra eventually turned up in the “Mississippi baby” isn't unexpected, says Robert Siliciano, MD, PhD, professor of medicine in the infectious diseases department at Johns Hopkins University School of Medicine. It supports the theory that HIV cells stay in the body, just out of view in a hidden "reservoir.""Curing HIV is going to require strategies to eliminate this reservoir," he says.Start Treatment EarlierPeople who have HIV should start treatment as soon as they know. That's easier to do for babies, who can be tested and retested right after they're born. Adults rarely know exactly when they're infected.If you're at risk, getting tested for HIV more often may lead to earlier, more effective treatment. Studies have found that those who adhere to their treatment and maintain a healthy lifestyle can not only live longer, but have virtually the same life expectancy as someone who is not infected.When someone tests positive in a clinic, for example, it might make sense for a doctor there to "start treatment and ask questions later," says David Hardy, MD, a board member of the HIV Medicine Association.

Still, patients will need to understand their diagnosis and the treatment and be willing to commit to what is currently a life-long treatment.And until there are better tests to find the kamagra hiding in the body, doctors can't accurately call anyone "HIV-free.".

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1. ACA Marketplace SubsidiesProvision DescriptionUnder the Affordable Care Act, people purchasing Marketplace coverage could only qualify for subsidies if they met other eligibility requirements and had incomes between one and four times the federal poverty level. People eligible for subsidies would have to contribute a sliding-scale percentage of their income toward a benchmark premium, ranging from 2.07% to 9.83%.

Once income passed 400% FPL, subsidies stopped and many individuals and families were unable to afford coverage.In 2021, the American Rescue Plan Act (ARPA) temporarily expanded eligibility for subsidies by removing the upper income threshold. It also temporarily increased the dollar value of premium subsidies across the board, meaning nearly everyone on the Marketplace paid lower premiums, and the lowest income people pay zero premium for coverage with very low deductibles. The ARPA also made people who received unemployment insurance (UI) benefits during 2021 eligible for zero-premium, low-deductible plans.However, the ARPA provisions removing the upper income threshold and increasing tax credit amounts are only in effect for 2021 and 2022.

The unemployment provision is only in effect for 2021.Section 137501 of The Build Back Better Act would make permanent ARPA subsidy changes that eliminate the income eligibility cap and increase the amount of APTC for individuals across the board.Additionally, Section 137507 of The Build Back Better Act would extend the special Marketplace subsidy rule for individuals receiving UI benefits for an additional 4 years, through the end of 2025.Finally, Section 237502 modifies the affordability test for employer-sponsored health coverage. The ACA makes people ineligible for marketplace subsidies if they have an offer of affordable coverage from an employer, currently defined as requiring an employee contribution of no more than 9.61% of household income in 2022. The Build Back Better Act would reduce this affordability threshold to 8.5% of income, bringing it in line with the maximum contribution required to enroll in the benchmark marketplace plan.People AffectedCBO projects that, under Section 137051, subsidized ACA Marketplace enrollment would increase by 3.6 million people (relative to the number of people who would be enrolled in the absence of these provisions).

CBO expects 1.4 million of these enrollees would otherwise be uninsured, while 600,000 would otherwise be covered by an unsubsidized individual market plan and 1.6 million would otherwise have employer coverage.Additionally, CBO expects the enhanced subsidies for people receiving unemployment insurance (Section 137507) would result in 500,000 people newly enrolling, on average per year during the 2022-2025 period. Most of these new enrollees would otherwise be uninsured.As of August 2021, 12.2 million people were actively enrolled in Marketplace plans – an 8% increase from 11.2 million people enrollees as of the close of Open Enrollment for the 2021 plan year. HealthCare.gov and all state Marketplaces reopened for a special enrollment period of at least 6 months in 2021, enrolling 2.8 million people (not all of whom were necessarily previously uninsured).

Of these, 44% selected plans with monthly premiums of $10 or less.The US Department of Health and Human Services (HHS) reports that ARPA reduced Marketplace premiums for the 8 million existing Healthcare.gov enrollees by $67 per month, on average. If the ARPA subsidies are allowed to expire, these enrollees will likely see their premium payments double.HHS also reports that between July 1 and August 15, more than 280,000 individuals received enhanced subsidies due to the ARPA UI provisions. Individuals eligible for these UI benefits can continue to enroll in 2021 coverage through the end of this year.The ARPA changes made people with income at or below 150% FPL eligible for zero-premium silver plans with comprehensive cost sharing subsidies.

40% of new consumers who signed up during the SEP are in a plan that covers 94% of expected costs (with average deductibles below $200). As a result of the ARPA, HHS reports the median deductible for new consumers selecting plan during the erectile dysfunction treatment-SEP decreased by more than 90% (from $750 in 2020 to $50 in 2021).With the ARPA and ACA subsidies, as well as Medicaid in states that expanded the program, we estimate that at least 46% of non-elderly uninsured people in the U.S. Are eligible for free or nearly-free health plans, often with low or no deductibles.Budgetary ImpactCBO published a score of certain provisions in the House Reconciliation legislation that affect coverage of nonelderly adults.CBO projects that, over the ten year period 2022-2031, the cost of permanently extending ARPA ACA subsidies (Section 137501) would be $209.5 billion.

The cost of Section 137507, which extends additional tax credits for people receiving unemployment insurance, would be $10.6 billion over the ten-year period of 2022-2031. Modification of the affordability test for employer-sponsored coverage (Section 137502) would cost $10.8 billion over the ten-year period.2. New Medicare Dental, Hearing, and Vision BenefitProvision DescriptionTraditional Medicare currently does not cover dental, vision, or hearing services, except under limited circumstances.

Dental, hearing, and vision services are typically offered by Medicare Advantage plans, which currently enroll more than 26 million Medicare beneficiaries, but according to our analysis, the extent of that coverage and the value of these benefits varies. Some beneficiaries in traditional Medicare may have private coverage or coverage through Medicaid for these services, but many do not – including nearly half of Medicare beneficiaries (24 million people) who did not have dental coverage as of 2019, based on our estimates. Our recent analysis found about half of all beneficiaries did not have a dental visit in the past year, with higher rates among Black and Hispanic beneficiaries.Sections 30901, 30902, and 30903 of the Build Back Better Act would add coverage of dental, hearing, and vision services to Medicare Part B.

Coverage of vision would begin in 2022, hearing in 2023, and dental in 2028.Covered dental services would include preventive and screening services such as oral exams, cleanings, and x-rays, major treatments such as crowns and root canals, and dentures. Coverage for hearing care would include hearing rehabilitation and treatment services by qualified audiologists, and hearing aids. Vision services would include routine eye examinations and contact lens fitting services, eyeglasses and contact lenses.

Cost sharing would apply to these services. The legislation specifies that the additional cost of providing dental benefits would not be factored into the determination of Part B premium.People AffectedAdding coverage of dental, hearing, and vision services to traditional Medicare would benefit up to all 62 million people on Medicare, but particularly the roughly 36 million beneficiaries in traditional Medicare who currently either lack coverage for these services or opt to purchase private coverage. A new, defined Medicare Part B benefit could also lead to enhanced dental, vision and hearing benefits for Medicare Advantage enrollees.

Because costs are often a barrier to care, adding these benefits to Medicare could increase use these services, and contribute to better health outcomes.Coverage of dental, hearing, and vision services under traditional Medicare also would make these services more affordable relative to what beneficiaries who use these services currently pay out of pocket. Our analysis shows that beneficiaries who use dental, vision, and hearing services can incur high out-of-pocket costs. Among beneficiaries who used each type of service in 2019, average spending was $914 for hearing care, $874 for dental care, and $230 for vision care.Budgetary ImpactCBO has not yet published budgetary estimates for these sections of the Build Back Better Act.However, according to a CBO estimate of an earlier version of H.R.3 passed by the House of Representatives in 2019, which included these same provisions, adding coverage of dental, vision, and hearing services to Medicare would lead to higher federal spending of $358 billion over 10 years (2020-2029), including $238 billion for dental and oral health care, $89 billion for hearing care, and $30.1 billion for vision care.3.

Controlling Prescription Drug Prices and SpendingProvision DescriptionCurrently, under the Medicare Part D program, which covers retail prescription drugs, Medicare contracts with private plan sponsors to provide a prescription drug benefit. The law that established the Part D benefit includes a provision known as the “noninterference” clause, which stipulates that the HHS Secretary “may not interfere with the negotiations between drug manufacturers and pharmacies and PDP [prescription drug plan] sponsors, and may not require a particular formulary or institute a price structure for the reimbursement of covered part D drugs.”In addition to the inability to negotiate drug prices under Part D, Medicare lacks the ability to limit annual price increases for drugs covered under Part B (which includes those administered by physicians) and Part D. In contrast, Medicaid has an inflationary rebate in place.

Year-to-year drug price increases exceeding inflation are not uncommon and affect people with both Medicare and private insurance. Our analysis shows that half of all covered Part D drugs had list price increases that exceeded the rate of inflation between 2018 and 2019.Section 139001 of the Build Back Better Act would amend the non-interference clause by adding an exception that would allow the federal government to negotiate prices with drug companies for a relatively small number of high-cost drugs lacking generic or biosimilar competitors. The negotiation process would apply to at least 25 (in 2025) and 50 (in 2026 and subsequent years) single-source brand-name drugs lacking generic or biosimilar competitors, selected from among the 125 drugs with the highest net Medicare Part D spending and the 125 drugs with the highest net spending in the U.S., which could include physician-administered drugs covered under Medicare Part B, along with all insulin products.The proposal to allow the government to negotiate drug prices establishes an upper limit for the negotiated price equal to 120% of the Average International Market (AIM) price paid by at least one of six applicable countries (Australia, Canada, France, Germany, Japan, and the United Kingdom).

The agreed-upon negotiated price would be made available to private plan sponsors in Medicare Part D and commercial payers in group and individual markets, and to providers that administer physician-administered drugs. An excise tax would be levied on drug companies that do not comply with the negotiation process, and civil monetary penalties would be imposed on companies that do not offer the agreed-upon negotiated price to any payer.Sections 139101 and 139102 of the Build Back Better Act would require drug manufacturers to pay a rebate to the federal government if their prices for drugs covered under Medicare Part B and Part D increase faster than the rate of inflation (CPI-U). Under these provisions, price changes would be measured based on the average sales price (for Part B drugs) or the average manufacturer price (for Part D drugs).

For price increase higher than inflation, manufacturers would be required to pay the difference in the form of a rebate to Medicare. The rebate amount is equal to the total number of units multiplied by the amount if any by which the manufacturer price exceeds the inflation-adjusted payment amount, including all units sold outside of Medicaid and therefore applying not only to use by Medicare beneficiaries but by privately insured individuals as well. Rebate dollars would be deposited in the Medicare Supplementary Medical Insurance (SMI) trust fund,Manufacturers that do not pay the requisite rebate amount within 30 days would be required to pay a penalty equal to 125% of the original rebate amount.

The base year for measuring price changes is 2016, and the provisions would take effect in 2023.People AffectedThe number of Medicare beneficiaries and privately insured individuals who would see lower out-of-pocket drug costs in any given year under these provisions would depend on how many and which drugs were subject to the negotiation process, and how many and which drugs had lower price increases, and the magnitude of price reductions relative to current prices under each provision.According to estimates from the CMS Office of the Actuary (OACT) of the drug price negotiation provision included in H.R.3 passed by the House of Representatives in 2019, allowing the federal government to negotiate drug prices would lower cost sharing for Part D enrollees by $102.6 billion in the aggregate (2020-2029) and Part D premiums for Medicare beneficiaries by $14.3 billion. Based on our analysis, premium savings for Medicare beneficiaries are projected to increase from an estimated 9% of the Part D base beneficiary premium in 2023 to 15% in 2029.Because the lower negotiated prices would also apply to private health insurers under the BBBA, people with private insurance would also face lower cost sharing for prescription drugs and premiums, according to OACT. Overall, people with private health insurance would save an estimated $54 billion between 2020 and 2029, including $25 billion in lower cost sharing for enrollees who use drugs subject to negotiation and $29 billion in savings due to lower premiums.While it is expected that some people would face lower cost sharing under these provisions, it is also possible that drug manufacturers could respond to the inflation rebate by increasing launch prices for new drugs.

In this case, some individuals could face higher out-of-pocket costs for new drugs that come to market, with potential spillover effects on total costs incurred by payers as well.A recent KFF Tracking Poll finds large majorities support allowing the federal government to negotiate and this support holds steady even after the public is provided the arguments being presented by parties on both sides of the legislative debate (83% total, 95% of Democrats, 82% of independents, and 71% of Republicans).Budgetary ImpactCBO has not yet published budgetary estimates for these sections of the Build Back Better Act.However, CBO estimated there would be over $450 billion in 10-year (2020-2029) savings from the Medicare drug price negotiation provision in drug price legislation considered in the 116th Congress (H.R. 3), including $448 billion in savings to Medicare and $12 billion in savings for subsidized plans in the ACA Marketplace and the Federal Employees Health Benefits Program. CBO also estimated an increase in revenues of about $45 billion over 10 years resulting from lower drug prices available to employers, which would reduce premiums for employer-sponsored insurance, leading to higher compensation in the form of taxable wages.A separate CBO estimate of the same Medicare drug price negotiation provision included in another House bill in the 116th Congress (H.R.

1425, the Patient Protection and Affordable Care Enhancement Act) estimated higher 10-year (2021-2030) savings of nearly $530 billion, mainly because the Secretary would negotiate prices for a somewhat larger set of drugs in year 2 of the negotiation program under H.R. 1425 (this change is incorporated in the current version of the Build Back Better Act).CBO estimated savings from the drug inflation rebate provisions in previous legislation (H.R. 3 and S.

2543, Senate Finance Committee legislation considered in the 116th Congress) amounting to $36 billion for H.R. 3 (2020-2029) and $82 billion for S. 2543 (2021-2030).

10-year savings were estimated to be lower under H.R. 3 because the inflation provision would not apply to drugs subject to the government negotiation process that would be established by that bill. This same exception applies in the Build Back Better Act.

However, because the Build Back Better Act applies the inflation rebate to use by private insurers as well as Medicare, it is possible that the savings from the inflation rebate provision would be larger than CBO estimated for either H.R. 3 or S. 2543.4.

Medicare Part D Benefit RedesignProvision DescriptionMedicare Part D currently provides catastrophic coverage for high out-of-pocket drug costs, but there is no limit on the total amount that beneficiaries pay out of pocket each year. Medicare Part D enrollees with drug costs high enough to exceed the catastrophic coverage threshold are required to pay 5% of their total drug costs unless they qualify for Part D Low-Income Subsidies (LIS). Medicare pays 80% of total costs above the catastrophic threshold and plans pay 15%.Under the current structure of Part D, there are multiple phases, including a deductible, an initial coverage phase, a coverage gap phase, and the catastrophic phase.

When enrollees reach the coverage gap benefit phase, they pay 25% of drug costs for both brand-name and generic drugs. Plan sponsors pay 5% for brands and 75% for generics. And drug manufacturers provide a 70% price discount on brands (no discount on generics).

Under the current benefit design, beneficiaries can face different cost-sharing amounts for the same medication depending on which phase of the benefit they are in, and can face significant out-of-pocket costs for high-priced drugs because of coinsurance requirements and no hard out-of-pocket cap.Section 139201 of the Build Back Better Act amends the design of the Part D benefit by adding a hard cap on out-of-pocket spending (set at $2,000 in 2024, and increasing each year based on the rate of increase in per capita Part D costs). It also lowers Medicare’s share of total costs above the catastrophic threshold from 80% to 20%, increases plans’ share of costs from 15% to 50%, and adds a 30% manufacturer price discount on brand-name drugs, instead of providing a 70% price discount for brands in the coverage gap, which would be phased out. Manufacturers would also be required to pay 10% of the costs in the initial coverage phase (prior to catastrophic coverage).People AffectedWhile most Part D enrollees have not had out-of-pocket costs high enough to exceed the catastrophic coverage threshold in a single year, the likelihood of a Medicare beneficiary incurring drug costs above the catastrophic threshold increases over a longer time span.Our analysis shows that in 2019, nearly 1.5 million Medicare Part D enrollees had out-of-pocket spending above the catastrophic coverage threshold.

Looking over a five-year period (2015-2019), the number of Part D enrollees with out-of-pocket spending above the catastrophic threshold in at least one year increases to 2.7 million, and over a 10-year period (2010-2019), the number of enrollees increases to 3.6 million.We also find that in 2019, nearly 1 million more Part D enrollees incurred out-of-pocket costs for their medications above $2,000, the proposed out-of-pocket spending limit in the Build Back Better Act, than above $3,100, the proposed out-of-pocket spending limit in recent GOP drug legislation (H.R. 19) and a 2019 Senate Finance Committee bill (S. 2543).

Overall, 1.2 million Part D enrollees in 2019 incurred annual out-of-pocket costs for their medications above $2,000, while 0.3 million spent more than $3,100 out of pocket.Medicare Part D enrollees with higher-than-average out-of-pocket costs could save substantial amounts with an out-of-pocket spending cap, as our analysis shows. For example, the top 10% of beneficiaries (122,000 enrollees) with average out-of-pocket costs for their medications above $2,000 in 2019 – who spent at least $5,348 – would have saved $3,348 (63%) in out-of-pocket costs with a $2,000 cap and $2,248 (42%) with a $3,100 cap.Budgetary ImpactCBO has not yet published budgetary estimates for this section of the Build Back Better Act.Adding a cap on out-of-pocket drug spending under Part D could add costs to the program, unless combined with other policies to lower Medicare drug spending (such as reducing the among Medicare now pays above the catastrophic threshold). A lower cap would help more beneficiaries and provide more out-of-pocket savings than a higher cap, but could mean higher costs for the federal government, plans, and drug manufacturers, depending on the specific features included in the Part D benefit redesign proposal.5.

Medicaid Coverage GapProvision DescriptionThere are currently 12 states that have not adopted the ACA provision to expand Medicaid to adults with incomes through 138% of poverty. The result is a coverage gap for individuals whose below-poverty-level income is too high to qualify for Medicaid in their state, but too low to be eligible for premium subsidies in the ACA Marketplace.Sections 137504, 137505 and 30701 of the Build Back Better Act would allow people living in states that have not expanded Medicaid to purchase subsidized coverage on the ACA Marketplace for 2022 to 2024. They would also be eligible for cost sharing subsidies that would reduce their out-of-pocket costs.

Beginning in 2025, a Federal Medicaid Program would be established to provide coverage to those with incomes up to 138% FPL. States that had expansion in place in January 2022 and then decide to end expansion coverage would be required make payments estimating the state costs for the expansion group.People AffectedCBO estimates that these provisions would increase the number of adult Medicaid enrollees by an average of 3.8 million people per year over the ten year period of 2022-2031. CBO estimates that about 2.3 million of those enrollees would otherwise be uninsured, 700,000 would otherwise have Marketplace coverage, and 900,000 would otherwise have employer coverage.

For the period in which people in the Medicaid coverage gap would be eligible for marketplace subsidies, enrollment would be somewhat lower.We estimate that 2.2 million uninsured people with incomes under poverty fall in the “coverage gap”. Most in the coverage gap are concentrated in four states (TX, FL, GA and NC) where eligibility levels for parents in Medicaid are low, and there is no coverage pathway for adults without dependent children. Half of those in the coverage gap are working and six in 10 are people of color.

Another 1.8 million uninsured people with incomes between 100% and 138% FPL in non-expansion states are eligible for subsidized marketplace coverage. In non-expansion state, there are also individuals with incomes 100-138% enrolled in marketplace coverage who would be eligible for coverage under the new Federal Medicaid Program in 2025.Budgetary ImpactCBO estimates that the federal cost of these provisions would be $323.1 billion over the 2022-2031 period. The estimate accounts for increased federal Medicaid spending partially offset by decreases in Marketplace subsidies.The total cost to the federal government will depend on the number of people who take up this coverage benefit, the cost per enrollee for coverage in the Marketplace or the new federal option, as well as the behavioral response of states and interaction with Marketplace coverage.6.

Maternity Care and Postpartum CoverageProvision DescriptionMedicaid currently covers almost half of births in the U.S. Federal law requires that pregnancy-related Medicaid coverage last through 60 days postpartum. After that period, some may qualify for Medicaid through another pathway, but others may not qualify, particularly in non-expansion states.

In an effort to improve maternal health and coverage stability and to help address racial disparities in maternal health, a provision in the American Rescue Plan Act (ARPA) of 2021 gives states a new option to extend Medicaid postpartum coverage to 12 months. This new option takes effect on April 1, 2022 and is available to states for five years.Section 30723 of the Build Back Better Act would require states to extend Medicaid postpartum coverage from 60 days to 12 months, ensuring continuity of Medicaid coverage for postpartum individuals in all states.Sections 31041 through 31056 of the Build Back Better Act provide federal grants to bolster other aspects of maternal health care. The funds would be used to address a wide range of issues, such as addressing social determinants of maternal health.

Diversifying the perinatal nursing workforce, expanding care for maternal mental health and substance use, and supporting research and programs that promote maternal health equity.People AffectedLargely in response to the new federal option, at least 25 states have taken steps to extend Medicaid postpartum coverage. Pregnant people in non-expansion states could see the biggest change as they are more likely than those in expansion states to become uninsured after the 60-day postpartum coverage period. For example, in Alabama, the Medicaid eligibility level for pregnant individuals is 146% FPL, but only 18% FPL (approximately $4,000/year for a family of three) for parents.The federal grant provisions related to maternal health could affect care for all persons giving birth, but the focus of these proposals is on reducing racial and ethnic inequities.

There were approximately 3.7 million births in 2019, and nearly half were to women of color. There are approximately 700-800 pregnancy-related deaths annually, with the rate 2-3 times higher among Black and American Indian and Alaska Native women compared to White women. Additionally, there are stark racial and ethnic disparities in other maternal and health outcomes, including preterm birth and infant mortality.Budgetary ImpactCBO has not yet published budgetary estimates for these sections of the Build Back Better Act.However, in June 2020, prior to the enactment of the ARPA option for postpartum coverage, CBO estimated that a proposal to require 12 month postpartum coverage in Medicaid and CHIP would have a net federal cost of $6 billion over 10 years (new costs of $12.3 billion offset by revenues).Total allocations in FY 2022 for the federal grant sections in the Build Back Better Act related to maternal health care outside of the postpartum extension are $1.05 billion.7.

Continuous Coverage for Children in Medicaid / CHIPProvision DescriptionUnder current law, states have the option to provide 12-months of continuous coverage for children. Under this option, states allow a child to remain enrolled for a full year unless the child ages out of coverage, moves out of state, voluntarily withdraws, or does not make premium payments. As such, 12-month continuous eligibility eliminates coverage gaps due to fluctuations in income over the course of the year.Section 30724 of the Build Back Better Act would require states to extend 12-month continuous coverage for children on Medicaid and CHIP.People AffectedAs of April 2021, there were 39 million children enrolled in Medicaid and CHIP (nearly half of all enrollees).

As of January 2020, 31 states provide 12-month continuous eligibility to children in either Medicaid or CHIP. A recent MACPAC report found that the overall mean length of coverage for children in 2018 was 11.7 months, and also that rates of churn (in which children dis-enroll and reenroll within a short period of time) were lower in states that had adopted the 12-month continuous coverage option and in states that did not conduct periodic data checks. Another recent report shows that children with gaps in coverage during a year are more likely to be children of color with lower incomes.Budgetary ImpactCBO has not yet published budgetary estimates for this section of the Build Back Better Act.Given that the length of coverage for children in Medicaid is already high (mean of 11.7 months), more than half of all states already have a continuous coverage policy in place, and costs for children are generally lower compared to other eligibility groups, new federal costs could be moderate.

In addition, reducing churn could modestly reduce Medicaid administrative costs.8. Permanent Extension of the Children’s Health Insurance Program (CHIP)Provision DescriptionUnder current law, Medicaid is the base of coverage for low-income children. CHIP complements Medicaid by covering uninsured children in families with incomes above Medicaid eligibility levels.

Unlike Medicaid, federal funding for CHIP is capped and provided as annual allotments to states. CHIP funding is authorized through September 30,2027. While CHIP generally has bipartisan support, during the last reauthorization funding lapsed before Congress reauthorized funding.Section 30801 of the Build Back Better Act would permanently extend the CHIP program.People AffectedAs of April 2021, there were 6.9 million people (mostly children) enrolled in CHIP.Budgetary ImpactCBO has not yet published budgetary estimates for this section of the Build Back Better Act.Federal CHIP funding in Fiscal Year (FY) 2020 for the states was $17.0 billion.

Since CHIP is authorized through FY 2027, CBO estimates would only account for costs in FY 2028 – FY 2031 (the current ten-year window). When CHIP was reauthorized through FY 2027, CBO estimated that this would result in net fiscal savings to the federal government because without CHIP, other alternatives would have higher federal costs and because of expected changes in the federal match rate back to traditional CHIP match rates.9. Medicaid Home and Community Based Services and the Direct Care WorkforceProvision DescriptionMedicaid is currently the primary payer for long-term services and supports (LTSS), including home and community-based services (HCBS), that help seniors and people with disabilities with daily self-care and independent living needs.

There is currently a great deal of state variation as most HCBS eligibility pathways and benefits are optional for states.Sections 30711-30715 of the Build Back Better Act would create the HCBS Improvement Program, which would provide a permanent 7 percentage point increase in federal Medicaid matching funds for HCBS. To qualify for the enhanced funds, states would have to maintain existing HCBS eligibility, benefits, and payment rates and have an approved plan to expand HCBS access, strengthen the direct care workforce, and monitor HCBS quality. The bill includes some provisions to support family caregivers.

In addition, the Act would include funding ($130 million) for state planning grants and enhanced funding for administrative costs for certain activities (80% instead of 50%).Sections 30721 and 30722 of the Build Back Better Act would make the Money Follows the Person (MFP) program and the ACA HCBS spousal impoverishment protections permanent.People AffectedThe majority of HCBS are provided by waivers, which served over 2.5 million enrollees in 2018. There is substantial unmet need for HCBS, which is expected to increase with the growth in the aging population in the coming years. Nearly 820,000 people in 41 states were on a Medicaid HCBS waiver waiting list in 2018.

Though waiting lists alone are an incomplete measure, they are one proxy for unmet need for HCBS. Additionally, a shortage of direct care workers predated and has been intensified by the erectile dysfunction treatment kamagra, characterized by low wages and limited opportunities for career advancement. The direct care workforce is disproportionately female and Black.Over 101,000 seniors and people with disabilities across 44 states and DC moved from nursing homes to the community using MFP funds from 2008-2019.

A federal evaluation of MFP showed about 5,000 new participants in each six month period from December 2013 through December 2016, indicating a continuing need for the program.A KFF survey found that, as of 2018, 14 states expected that allowing the ACA provision to expire would affect Medicaid HCBS enrollees, for example by making fewer individuals eligible for waiver services.Budgetary ImpactCBO has not yet published budgetary estimates for these sections of the Build Back Better Act.The House Energy and Commerce Committee markup of the bill described the cost to the federal government as $190 billion. This is less than the $400 billion originally proposed by President Biden. While the program requirements are not the same, CBO previously estimated that the American Rescue Plan Act’s 10 percentage point increase in federal matching funds for Medicaid HCBS for 1 year would increase federal costs by about $12.7 billion.10.

Paid Family and Medical LeaveProvision DescriptionThe U.S. Is the only industrialized nation without a minimum standard of paid family or medical leave. Although six states and DC have paid family and medical leave laws in effect, and some employers voluntarily offer these benefits, this has resulted in a patchwork of policies with varying degrees of generosity and leaves many workers without a financial safety net when they need to take time off work to care for themselves or their families.Section 130001 of the Build Back Better Act would guarantee 12 weeks per year of paid family and medical leave annually to all workers in the U.S.

Who need time off work to welcome a new child, recover from a serious illness, care for a seriously ill family member, or for certain military-related reasons. Also included is three days of paid bereavement leave. The progressive benefits formula means that that the amount of pay replaced while on qualified leave is higher for workers with lower wages, with 85% wage replacement for individuals earning about $15,080/year.

While all workers taking qualified leave would be eligible for at least some wage replacement, earnings above $250,000/year are not included in the benefit formula.People AffectedAccording to the Bureau of Labor Statistics, one in five (21%) workers have access to paid family leave through their employer. It is estimated that 53 million adults are caregivers for a dependent child or adult and 61% of them are women. Sixty percent (60%) of caregivers reported having to take a leave of absence leave from work or cut their hours in order to care for a family member.

Workers who take leave do so for different reasons. Half (51%) reported taking leave due to their own serious illness, one-quarter (25%) for reasons related to pregnancy, childbirth, or bonding with a new child, and one-fifth (19%) to care for a seriously ill family member. In total, four in ten (42%) reported receiving their full pay while on leave, one-quarter (24%) received partial pay, and one-third (34%) received no pay.Budgetary ImpactCBO has not yet published budgetary estimates for this section of the Build Back Better Act.However, unofficial estimates reportedly put the cost at $494 billion over ten years.

A 2019 CBO estimate of the proposed Democratic-led FAMILY Act, which is similar to the current proposal, estimated that program would cost $547 billion over ten years.SOURCE. KFFKey FindingsThe October KFF Health Tracking Poll finds one in five adults in the U.S. Report receiving ongoing support for daily activities such as bathing, dressing, or remembering medications, and a similar share say they are providing those type of services for a close friend or family member.

About one in five adults (18%) also say they or a family member need either new or additional support from paid nurses or aides beyond what they are currently getting. The most common reason why people haven’t gotten the support they need is cost. More than three-fourths of those who say they need more help (14% of all adults) say “not being able to afford the cost of the care” is a reason why they or their family member has not received the additional support from paid nurses or aides.Many unpaid caregivers say providing support to friends or family members has caused them to worry or stress (77%), experience worsening of their own mental health (50%), financial strain due to inability to work (42%), or worsening of their own physical health (38%).

Unpaid caregivers are more likely to be racial and ethnic minorities, those with lower education, and report lower levels of household income.Significant shares of older adults in the U.S. Report difficulty paying for various aspects of health care, especially services not generally covered by Medicare. Four in ten older adults (41%) report difficulty paying for dental care while three in ten report difficulty affording hearing or vision care (30%).

Dental, vision, and hearing coverage are three benefits not generally covered by Medicare but are part of Democratic lawmakers’ proposals as part of the reconciliation spending package.Many older adults who are eligible for Medicare also report putting off or foregoing medical care due to costs. While Medicare helps older adults pay for routine doctor visits and hospital stays, substantial shares of lower income older adults report putting off or foregoing services not covered by Medicare. Overall, more than four in ten older adults in households earning less than $40,000 annually report delaying or going without some form of medical care over the past year due to costs (compared to 24% of older adults with household incomes over $40,000), including dental care (34%), vision care (20%), and hearing services including hearing aids (16%).With substantial shares of the public reporting financial strains associated with help with everyday activities for themselves or family members, and seniors reporting difficulty paying for some health care expenses, the latest KFF poll finds broad support for many of the proposals in the reconciliation package being currently discussed in Congress.Home And Community Based ServicesOne in five adults, including 27% of adults 65 and older, say they are currently receiving ongoing support with everyday activities from either a family member (19%), a friend (11%), or paid nurses or aides (5%).

Additionally, nearly four in ten (38%) adults say a family member gets ongoing help from at least one of these sources including another family member (30%), paid nurses or aides (16%) or friends (12%). About one in five adults (18%) say they or a family member need either new or additional support from paid nurses or aides beyond what they are currently getting. The most common reason why people haven’t gotten the support they need is cost.

More than three-fourths of those who say they need more help (14% of all adults) say “not being able to afford the cost of the care” is a reason why they or their family member has not received the additional support from paid nurses or aides. Other reasons include not being able to find someone to provide the services (47%, or 8% of all adults), being worried about being exposed to erectile dysfunction (40%, 7% of all adults), being afraid or embarrassed to get help (32%, 6%), or being too busy or unable to find the time to get help (20%, 4%). With many reporting difficulty paying for cost of home and community based care, the poll also gauged support for Democratic proposals to increase funding to Medicaid to pay workers and expand home and community-based services (HCBS).

Medicaid is the primary payer for long-term services and supports (LTSS), including home and community-based services (HCBS), that help seniors and people with disabilities with daily self-care and independent living needs. Majorities across partisans (79% total, 95% of Democrats, 76% of independents, 67% of Republicans) support increased funding to Medicaid to pay workers and expand home and community-based services (HCBS).The toll On Unpaid CaregiversWith Congress discussing possible new tax credits to help with home and community based care, one in five adults (21%) say they are currently providing unpaid support with everyday activities to either a friend or family member, excluding the type of care young children need. Majorities across partisans also favor new tax credit to help people pay for such care (82% total, 94% of Democrats, 80% of independents, 73% of Republicans).The KFF October Tracking Poll finds unpaid caregivers are more likely to be Black or Hispanic (14% and 21%) compared to those who are not unpaid caregivers (10% and 15%).

About eight in ten unpaid caregivers to family and friends do not have a college degree, and about half have household incomes under $40,000. Consistent with recent focus groups conducted by KFF, the poll finds most unpaid caregivers (85%, 18% of all adults) report experiencing at least one of several negative outcomes due to their caregiving responsibilities. Over three-fourths of unpaid caregivers (16% of all adults) say they have experienced stress or worry related to the care of the individual they are caring for, with an additional half (11% of all adults) say they have experienced a worsening of their own mental health as a result of providing this ongoing support.

About four in ten (9% of total) say they have experienced financial strain, such as losing a job or having to work reduced hours. A similar share (38% and 8% of total) also say they have experienced a worsening of their own physical health. Expanding Medicare BenefitsWith Congress debating changes to the current Medicare program, eight in ten adults—and nearly all older adults—say Medicare is important to them and their family members.

This includes at least seven in ten adults across partisanship, income groups, and racial and ethnic identity. Significant shares of older adults in the U.S. Report difficulty paying for various aspects of health care, especially services not generally covered by Medicare.

Four in ten older adults (41%) report difficulty paying for dental care while three in ten report difficulty affording hearing or vision care (30%). Two in ten report difficulty affording their prescription drugs. Additionally, one-third report difficulty affording their out-of-pocket health care costs and one in five report the same about their monthly health insurance costs – shares comparable to those who report difficulty affording other household expenses such as rent or mortgage, gasoline, monthly utilities, or food and groceries.

Dental services are the most common type of medical care that people have delayed or gone without with about with about one in four (23%) of adults ages 65 and older saying they have put off dental care in the past year due to cost. This is followed by vision services or eyeglasses (15%) and hearing aids (13%). Dental, vision, and hearing coverage are three benefits not generally covered by Medicare.Few older adults report delaying or going without a doctor’s office visit (6%), hospital services (5%) or mental health care (2%) due to cost.

Overall, three in ten adults 65 and older report delaying or going without certain medical care during the past year due to cost (32%). Even among older adults who are eligible for Medicare, those with lower incomes report delaying or going without care at higher rates. More than four in ten older adults in households earning less than $40,000 annually report delaying or going without some form of medical care over the past year due to costs (compared to 24% of older adults with household incomes over $40,000).

While Medicare helps older adults pay for routine doctor visits and hospital stays, substantial shares of lower income older adults report putting off or foregoing dental care (34%), vision care (20%), and hearing services including hearing aids (16%) that are not generally covered by Medicare. A large majority of the public (90%) favor expanding Medicare coverage to include dental, vision, and hearing coverage, including 97% of Democrats, 90% of independents, and 85% of Republicans. This proposal is also largely favored by adults 65 and older, including 96% of those in that age group who identify as Democrats or Democratic-leaning and 82% of their Republican counterparts.

Proposals aimed at curbing the price individuals have to pay for their prescription drugs are favored by majorities of the public with at least eight in ten overall and at least three-fourths across partisans saying they favor each of the proposals asked about. Eighty-eight percent of adults favor limiting how much drug companies can increase the price for prescription drugs each year to not outpace the rate of inflation (including 93% of Democrats, 86% of independents, 89% of Republicans) and a similar share (85%) favor placing an annual limit on out-of-pocket prescription drug costs for people on Medicare (favored by 88% of Democrats, 85% of independents, 84% of Republicans). The proposed changes to Medicare drug negotiations as part of the reconciliation package poll findings were released earlier this week.The Affordable Care ActViews of the 2010 Affordable Care Act are still largely driven by party identification with nearly nine in ten Democrats saying they view the law favorably, while three-fourths of Republicans say they hold an unfavorable view.

Independents are slightly more favorable than unfavorable with more than half saying they hold a positive opinion of the ACA. KFF has been polling on the ACA since its passage and since 2017 views have been more favorable than unfavorable but still sharply divided on party lines. The erectile dysfunction treatment relief bill passed in early March 2021 providing additional financial help for people who buy their own health insurance coverage.

Previous KFF polling found that a small minority of those likely eligible for additional financial help or coverage reporting going online to see if they qualify for a different or cheaper health insurance plan.Among those under 65 years old, nine percent of those who are either uninsured or buy their own coverage reported going online in the in the two months before mid-May 2021 to see if they qualify for a different or cheaper health insurance plan or Medicaid as part of the erectile dysfunction treatment relief package. Four months later, the latest KFF polling finds that about one in four (23%) of those likely eligible for this assistance have gone online to see if they qualify, though majorities (75%) still have not. In addition, changes to health insurance coverage provided under the Affordable Care Act continue to be seen through a partisan lens, with overwhelming majorities of Democrats and smaller majorities of Republicans expressing support.

Overall, eight in ten adults favor making permanent the financial help to low- and moderate- income Americans who buy their own health insurance coverage (94% of Democrats, 79% of independents, 63% of Republicans). Three in four favor the federal government stepping in to provide insurance options for lower income people living in states that haven’t expanded their Medicaid programs (94% of Democrats, 76% of independents) but this is supported by a small majority (54%) of Republicans.While the poll finds broad support for many of the Democratic proposed changes to the country’s health care system including the ACA, Medicaid, and Medicare, the poll did not ask about the potential costs and savings associated with each provision, or the size and scope of Democrats’ broader legislative plan, which includes many provisions unrelated to health care. Methodology.

1. ACA Marketplace SubsidiesProvision DescriptionUnder the Affordable Care Act, people purchasing Marketplace coverage could only qualify for subsidies if they met other eligibility requirements and had incomes between one and four times the federal poverty level. People eligible for subsidies would have to contribute a sliding-scale percentage of their income toward a benchmark premium, ranging from 2.07% to 9.83%. Once income passed 400% FPL, subsidies stopped and many individuals and families were unable to afford coverage.In 2021, the American Rescue Plan Act (ARPA) temporarily expanded eligibility for subsidies by removing the upper income threshold.

It also temporarily increased the dollar value of premium subsidies across the board, meaning nearly everyone on the Marketplace paid lower premiums, and the lowest income people pay zero premium for coverage with very low deductibles. The ARPA also made people who received unemployment insurance (UI) benefits during 2021 eligible for zero-premium, low-deductible plans.However, the ARPA provisions removing the upper income threshold and increasing tax credit amounts are only in effect for 2021 and 2022. The unemployment provision is only in effect for 2021.Section 137501 of The Build Back Better Act would make permanent ARPA subsidy changes that eliminate the income eligibility cap and increase the amount of APTC for individuals across the board.Additionally, Section 137507 of The Build Back Better Act would extend the special Marketplace subsidy rule for individuals receiving UI benefits for an additional 4 years, through the end of 2025.Finally, Section 237502 modifies the affordability test for employer-sponsored health coverage. The ACA makes people ineligible for marketplace subsidies if they have an offer of affordable coverage from an employer, currently defined as requiring an employee contribution of no more than 9.61% of household income in 2022.

The Build Back Better Act would reduce this affordability threshold to 8.5% of income, bringing it in line with the maximum contribution required to enroll in the benchmark marketplace plan.People AffectedCBO projects that, under Section 137051, subsidized ACA Marketplace enrollment would increase by 3.6 million people (relative to the number of people who would be enrolled in the absence of these provisions). CBO expects 1.4 million of these enrollees would otherwise be uninsured, while 600,000 would otherwise be covered by an unsubsidized individual market plan and 1.6 million would otherwise have employer coverage.Additionally, CBO expects the enhanced subsidies for people receiving unemployment insurance (Section 137507) would result in 500,000 people newly enrolling, on average per year during the 2022-2025 period. Most of these new enrollees would otherwise be uninsured.As of August 2021, 12.2 million people were actively enrolled in Marketplace plans – an 8% increase from 11.2 million people enrollees as of the close of Open Enrollment for the 2021 plan year. HealthCare.gov and all state Marketplaces reopened for a special enrollment period of at least 6 months in 2021, enrolling 2.8 million people (not all of whom were necessarily previously uninsured).

Of these, 44% selected plans with monthly premiums of $10 or less.The US Department of Health and Human Services (HHS) reports that ARPA reduced Marketplace premiums for the 8 million existing Healthcare.gov enrollees by $67 per month, on average. If the ARPA subsidies are allowed to expire, these enrollees will likely see their premium payments double.HHS also reports that between July 1 and August 15, more than 280,000 individuals received enhanced subsidies due to the ARPA UI provisions. Individuals eligible for these UI benefits can continue to enroll in 2021 coverage through the end of this year.The ARPA changes made people with income at or below 150% FPL eligible for zero-premium silver plans with comprehensive cost sharing subsidies. 40% of new consumers who signed up during the SEP are in a plan that covers 94% of expected costs (with average deductibles below $200).

As a result of the ARPA, HHS reports the median deductible for new consumers selecting plan during the erectile dysfunction treatment-SEP decreased by more than 90% (from $750 in 2020 to $50 in 2021).With the ARPA and ACA subsidies, as well as Medicaid in states that expanded the program, we estimate that at least 46% of non-elderly uninsured people in the U.S. Are eligible for free or nearly-free health plans, often with low or no deductibles.Budgetary ImpactCBO published a score of certain provisions in the House Reconciliation legislation that affect coverage of nonelderly adults.CBO projects that, over the ten year period 2022-2031, the cost of permanently extending ARPA ACA subsidies (Section 137501) would be $209.5 billion. The cost of Section 137507, which extends additional tax credits for people receiving unemployment insurance, would be $10.6 billion over the ten-year period of 2022-2031. Modification of the affordability test for employer-sponsored coverage (Section 137502) would cost $10.8 billion over the ten-year period.2.

New Medicare Dental, Hearing, and Vision BenefitProvision DescriptionTraditional Medicare currently does not cover dental, vision, or hearing services, except under limited circumstances. Dental, hearing, and vision services are typically offered by Medicare Advantage plans, which currently enroll more than 26 million Medicare beneficiaries, but according to our analysis, the extent of that coverage and the value of these benefits varies. Some beneficiaries in traditional Medicare may have private coverage or coverage through Medicaid for these services, but many do not – including nearly half of Medicare beneficiaries (24 million people) who did not have dental coverage as of 2019, based on our estimates. Our recent analysis found about half of all beneficiaries did not have a dental visit in the past year, with higher rates among Black and Hispanic beneficiaries.Sections 30901, 30902, and 30903 of the Build Back Better Act would add coverage of dental, hearing, and vision services to Medicare Part B.

Coverage of vision would begin in 2022, hearing in 2023, and dental in 2028.Covered dental services would include preventive and screening services such as oral exams, cleanings, and x-rays, major treatments such as crowns and root canals, and dentures. Coverage for hearing care would include hearing rehabilitation and treatment services by qualified audiologists, and hearing aids. Vision services would include routine eye examinations and contact lens fitting services, eyeglasses and contact lenses. Cost sharing would apply to these services.

The legislation specifies that the additional cost of providing dental benefits would not be factored into the determination of Part B premium.People AffectedAdding coverage of dental, hearing, and vision services to traditional Medicare would benefit up to all 62 million people on Medicare, but particularly the roughly 36 million beneficiaries in traditional Medicare who currently either lack coverage for these services or opt to purchase private coverage. A new, defined Medicare Part B benefit could also lead to enhanced dental, vision and hearing benefits for Medicare Advantage enrollees. Because costs are often a barrier to care, adding these benefits to Medicare could increase use these services, and contribute to better health outcomes.Coverage of dental, hearing, and vision services under traditional Medicare also would make these services more affordable relative to what beneficiaries who use these services currently pay out of pocket. Our analysis shows that beneficiaries who use dental, vision, and hearing services can incur high out-of-pocket costs.

Among beneficiaries who used each type of service in 2019, average spending was $914 for hearing care, $874 for dental care, and $230 for vision care.Budgetary ImpactCBO has not yet published budgetary estimates for these sections of the Build Back Better Act.However, according to a CBO estimate of an earlier version of H.R.3 passed by the House of Representatives in 2019, which included these same provisions, adding coverage of dental, vision, and hearing services to Medicare would lead to higher federal spending of $358 billion over 10 years (2020-2029), including $238 billion for dental and oral health care, $89 billion for hearing care, and $30.1 billion for vision care.3. Controlling Prescription Drug Prices and SpendingProvision DescriptionCurrently, under the Medicare Part D program, which covers retail prescription drugs, Medicare contracts with private plan sponsors to provide a prescription drug benefit. The law that established the Part D benefit includes a provision known as the “noninterference” clause, which stipulates that the HHS Secretary “may not interfere with the negotiations between drug manufacturers and pharmacies and PDP [prescription drug plan] sponsors, and may not require a particular formulary or institute a price structure for the reimbursement of covered part D drugs.”In addition to the inability to negotiate drug prices under Part D, Medicare lacks the ability to limit annual price increases for drugs covered under Part B (which includes those administered by physicians) and Part D. In contrast, Medicaid has an inflationary rebate in place.

Year-to-year drug price increases exceeding inflation are not uncommon and affect people with both Medicare and private insurance. Our analysis shows that half of all covered Part D drugs had list price increases that exceeded the rate of inflation between 2018 and 2019.Section 139001 of the Build Back Better Act would amend the non-interference clause by adding an exception that would allow the federal government to negotiate prices with drug companies for a relatively small number of high-cost drugs lacking generic or biosimilar competitors. The negotiation process would apply to at least 25 (in 2025) and 50 (in 2026 and subsequent years) single-source brand-name drugs lacking generic or biosimilar competitors, selected from among the 125 drugs with the highest net Medicare Part D spending and the 125 drugs with the highest net spending in the U.S., which could include physician-administered drugs covered under Medicare Part B, along with all insulin products.The proposal to allow the government to negotiate drug prices establishes an upper limit for the negotiated price equal to 120% of the Average International Market (AIM) price paid by at least one of six applicable countries (Australia, Canada, France, Germany, Japan, and the United Kingdom). The agreed-upon negotiated price would be made available to private plan sponsors in Medicare Part D and commercial payers in group and individual markets, and to providers that administer physician-administered drugs.

An excise tax would be levied on drug companies that do not comply with the negotiation process, and civil monetary penalties would be imposed on companies that do not offer the agreed-upon negotiated price to any payer.Sections 139101 and 139102 of the Build Back Better Act would require drug manufacturers to pay a rebate to the federal government if their prices for drugs covered under Medicare Part B and Part D increase faster than the rate of inflation (CPI-U). Under these provisions, price changes would be measured based on the average sales price (for Part B drugs) or the average manufacturer price (for Part D drugs). For price increase higher than inflation, manufacturers would be required to pay the difference in the form of a rebate to Medicare. The rebate amount is equal to the total number of units multiplied by the amount if any by which the manufacturer price exceeds the inflation-adjusted payment amount, including all units sold outside of Medicaid and therefore applying not only to use by Medicare beneficiaries but by privately insured individuals as well.

Rebate dollars would be deposited in the Medicare Supplementary Medical Insurance (SMI) trust fund,Manufacturers that do not pay the requisite rebate amount within 30 days would be required to pay a penalty equal to 125% of the original rebate amount. The base year for measuring price changes is 2016, and the provisions would take effect in 2023.People AffectedThe number of Medicare beneficiaries and privately insured individuals who would see lower out-of-pocket drug costs in any given year under these provisions would depend on how many and which drugs were subject to the negotiation process, and how many and which drugs had lower price increases, and the magnitude of price reductions relative to current prices under each provision.According to estimates from the CMS Office of the Actuary (OACT) of the drug price negotiation provision included in H.R.3 passed by the House of Representatives in 2019, allowing the federal government to negotiate drug prices would lower cost sharing for Part D enrollees by $102.6 billion in the aggregate (2020-2029) and Part D premiums for Medicare beneficiaries by $14.3 billion. Based on our analysis, premium savings for Medicare beneficiaries are projected to increase from an estimated 9% of the Part D base beneficiary premium in 2023 to 15% in 2029.Because the lower negotiated prices would also apply to private health insurers under the BBBA, people with private insurance would also face lower cost sharing for prescription drugs and premiums, according to OACT. Overall, people with private health insurance would save an estimated $54 billion between 2020 and 2029, including $25 billion in lower cost sharing for enrollees who use drugs subject to negotiation and $29 billion in savings due to lower premiums.While it is expected that some people would face lower cost sharing under these provisions, it is also possible that drug manufacturers could respond to the inflation rebate by increasing launch prices for new drugs.

In this case, some individuals could face higher out-of-pocket costs for new drugs that come to market, with potential spillover effects on total costs incurred by payers as well.A recent KFF Tracking Poll finds large majorities support allowing the federal government to negotiate and this support holds steady even after the public is provided the arguments being presented by parties on both sides of the legislative debate (83% total, 95% of Democrats, 82% of independents, and 71% of Republicans).Budgetary ImpactCBO has not yet published budgetary estimates for these sections of the Build Back Better Act.However, CBO estimated there would be over $450 billion in 10-year (2020-2029) savings from the Medicare drug price negotiation provision in drug price legislation considered in the 116th Congress (H.R. 3), including $448 billion in savings to Medicare and $12 billion in savings for subsidized plans in the ACA Marketplace and the Federal Employees Health Benefits Program. CBO also estimated an increase in revenues of about $45 billion over 10 years resulting from lower drug prices available to employers, which would reduce premiums for employer-sponsored insurance, leading to higher compensation in the form of taxable wages.A separate CBO estimate of the same Medicare drug price negotiation provision included in another House bill in the 116th Congress (H.R. 1425, the Patient Protection and Affordable Care Enhancement Act) estimated higher 10-year (2021-2030) savings of nearly $530 billion, mainly because the Secretary would negotiate prices for a somewhat larger set of drugs in year 2 of the negotiation program under H.R.

1425 (this change is incorporated in the current version of the Build Back Better Act).CBO estimated savings from the drug inflation rebate provisions in previous legislation (H.R. 3 and S. 2543, Senate Finance Committee legislation considered in the 116th Congress) amounting to $36 billion for H.R. 3 (2020-2029) and $82 billion for S.

2543 (2021-2030). 10-year savings were estimated to be lower under H.R. 3 because the inflation provision would not apply to drugs subject to the government negotiation process that would be established by that bill. This same exception applies in the Build Back Better Act.

However, because the Build Back Better Act applies the inflation rebate to use by private insurers as well as Medicare, it is possible that the savings from the inflation rebate provision would be larger than CBO estimated for either H.R. 3 or S. 2543.4. Medicare Part D Benefit RedesignProvision DescriptionMedicare Part D currently provides catastrophic coverage for high out-of-pocket drug costs, but there is no limit on the total amount that beneficiaries pay out of pocket each year.

Medicare Part D enrollees with drug costs high enough to exceed the catastrophic coverage threshold are required to pay 5% of their total drug costs unless they qualify for Part D Low-Income Subsidies (LIS). Medicare pays 80% of total costs above the catastrophic threshold and plans pay 15%.Under the current structure of Part D, there are multiple phases, including a deductible, an initial coverage phase, a coverage gap phase, and the catastrophic phase. When enrollees reach the coverage gap benefit phase, they pay 25% of drug costs for both brand-name and generic drugs. Plan sponsors pay 5% for brands and 75% for generics.

And drug manufacturers provide a 70% price discount on brands (no discount on generics). Under the current benefit design, beneficiaries can face different cost-sharing amounts for the same medication depending on which phase of the benefit they are in, and can face significant out-of-pocket costs for high-priced drugs because of coinsurance requirements and no hard out-of-pocket cap.Section 139201 of the Build Back Better Act amends the design of the Part D benefit by adding a hard cap on out-of-pocket spending (set at $2,000 in 2024, and increasing each year based on the rate of increase in per capita Part D costs). It also lowers Medicare’s share of total costs above the catastrophic threshold from 80% to 20%, increases plans’ share of costs from 15% to 50%, and adds a 30% manufacturer price discount on brand-name drugs, instead of providing a 70% price discount for brands in the coverage gap, which would be phased out. Manufacturers would also be required to pay 10% of the costs in the initial coverage phase (prior to catastrophic coverage).People AffectedWhile most Part D enrollees have not had out-of-pocket costs high enough to exceed the catastrophic coverage threshold in a single year, the likelihood of a Medicare beneficiary incurring drug costs above the catastrophic threshold increases over a longer time span.Our analysis shows that in 2019, nearly 1.5 million Medicare Part D enrollees had out-of-pocket spending above the catastrophic coverage threshold.

Looking over a five-year period (2015-2019), the number of Part D enrollees with out-of-pocket spending above the catastrophic threshold in at least one year increases to 2.7 million, and over a 10-year period (2010-2019), the number of enrollees increases to 3.6 million.We also find that in 2019, nearly 1 million more Part D enrollees incurred out-of-pocket costs for their medications above $2,000, the proposed out-of-pocket spending limit in the Build Back Better Act, than above $3,100, the proposed out-of-pocket spending limit in recent GOP drug legislation (H.R. 19) and a 2019 Senate Finance Committee bill (S. 2543). Overall, 1.2 million Part D enrollees in 2019 incurred annual out-of-pocket costs for their medications above $2,000, while 0.3 million spent more than $3,100 out of pocket.Medicare Part D enrollees with higher-than-average out-of-pocket costs could save substantial amounts with an out-of-pocket spending cap, as our analysis shows.

For example, the top 10% of beneficiaries (122,000 enrollees) with average out-of-pocket costs for their medications above $2,000 in 2019 – who spent at least $5,348 – would have saved $3,348 (63%) in out-of-pocket costs with a $2,000 cap and $2,248 (42%) with a $3,100 cap.Budgetary ImpactCBO has not yet published budgetary estimates for this section of the Build Back Better Act.Adding a cap on out-of-pocket drug spending under Part D could add costs to the program, unless combined with other policies to lower Medicare drug spending (such as reducing the among Medicare now pays above the catastrophic threshold). A lower cap would help more beneficiaries and provide more out-of-pocket savings than a higher cap, but could mean higher costs for the federal government, plans, and drug manufacturers, depending on the specific features included in the Part D benefit redesign proposal.5. Medicaid Coverage GapProvision DescriptionThere are currently 12 states that have not adopted the ACA provision to expand Medicaid to adults with incomes through 138% of poverty. The result is a coverage gap for individuals whose below-poverty-level income is too high to qualify for Medicaid in their state, but too low to be eligible for premium subsidies in the ACA Marketplace.Sections 137504, 137505 and 30701 of the Build Back Better Act would allow people living in states that have not expanded Medicaid to purchase subsidized coverage on the ACA Marketplace for 2022 to 2024.

They would also be eligible for cost sharing subsidies that would reduce their out-of-pocket costs. Beginning in 2025, a Federal Medicaid Program would be established to provide coverage to those with incomes up to 138% FPL. States that had expansion in place in January 2022 and then decide to end expansion coverage would be required make payments estimating the state costs for the expansion group.People AffectedCBO estimates that these provisions would increase the number of adult Medicaid enrollees by an average of 3.8 million people per year over the ten year period of 2022-2031. CBO estimates that about 2.3 million of those enrollees would otherwise be uninsured, 700,000 would otherwise have Marketplace coverage, and 900,000 would otherwise have employer coverage.

For the period in which people in the Medicaid coverage gap would be eligible for marketplace subsidies, enrollment would be somewhat lower.We estimate that 2.2 million uninsured people with incomes under poverty fall in the “coverage gap”. Most in the coverage gap are concentrated in four states (TX, FL, GA and NC) where eligibility levels for parents in Medicaid are low, and there is no coverage pathway for adults without dependent children. Half of those in the coverage gap are working and six in 10 are people of color. Another 1.8 million uninsured people with incomes between 100% and 138% FPL in non-expansion states are eligible for subsidized marketplace coverage.

In non-expansion state, there are also individuals with incomes 100-138% enrolled in marketplace coverage who would be eligible for coverage under the new Federal Medicaid Program in 2025.Budgetary ImpactCBO estimates that the federal cost of these provisions would be $323.1 billion over the 2022-2031 period. The estimate accounts for increased federal Medicaid spending partially offset by decreases in Marketplace subsidies.The total cost to the federal government will depend on the number of people who take up this coverage benefit, the cost per enrollee for coverage in the Marketplace or the new federal option, as well as the behavioral response of states and interaction with Marketplace coverage.6. Maternity Care and Postpartum CoverageProvision DescriptionMedicaid currently covers almost half of births in the U.S. Federal law requires that pregnancy-related Medicaid coverage last through 60 days postpartum.

After that period, some may qualify for Medicaid through another pathway, but others may not qualify, particularly in non-expansion states. In an effort to improve maternal health and coverage stability and to help address racial disparities in maternal health, a provision in the American Rescue Plan Act (ARPA) of 2021 gives states a new option to extend Medicaid postpartum coverage to 12 months. This new option takes effect on April 1, 2022 and is available to states for five years.Section 30723 of the Build Back Better Act would require states to extend Medicaid postpartum coverage from 60 days to 12 months, ensuring continuity of Medicaid coverage for postpartum individuals in all states.Sections 31041 through 31056 of the Build Back Better Act provide federal grants to bolster other aspects of maternal health care. The funds would be used to address a wide range of issues, such as addressing social determinants of maternal health.

Diversifying the perinatal nursing workforce, expanding care for maternal mental health and substance use, and supporting research and programs that promote maternal health equity.People AffectedLargely in response to the new federal option, at least 25 states have taken steps to extend Medicaid postpartum coverage. Pregnant people in non-expansion states could see the biggest change as they are more likely than those in expansion states to become uninsured after the 60-day postpartum coverage period. For example, in Alabama, the Medicaid eligibility level for pregnant individuals is 146% FPL, but only 18% FPL (approximately $4,000/year for a family of three) for parents.The federal grant provisions related to maternal health could affect care for all persons giving birth, but the focus of these proposals is on reducing racial and ethnic inequities. There were approximately 3.7 million births in 2019, and nearly half were to women of color.

There are approximately 700-800 pregnancy-related deaths annually, with the rate 2-3 times higher among Black and American Indian and Alaska Native women compared to White women. Additionally, there are stark racial and ethnic disparities in other maternal and health outcomes, including preterm birth and infant mortality.Budgetary ImpactCBO has not yet published budgetary estimates for these sections of the Build Back Better Act.However, in June 2020, prior to the enactment of the ARPA option for postpartum coverage, CBO estimated that a proposal to require 12 month postpartum coverage in Medicaid and CHIP would have a net federal cost of $6 billion over 10 years (new costs of $12.3 billion offset by revenues).Total allocations in FY 2022 for the federal grant sections in the Build Back Better Act related to maternal health care outside of the postpartum extension are $1.05 billion.7. Continuous Coverage for Children in Medicaid / CHIPProvision DescriptionUnder current law, states have the option to provide 12-months of continuous coverage for children. Under this option, states allow a child to remain enrolled for a full year unless the child ages out of coverage, moves out of state, voluntarily withdraws, or does not make premium payments.

As such, 12-month continuous eligibility eliminates coverage gaps due to fluctuations in income over the course of the year.Section 30724 of the Build Back Better Act would require states to extend 12-month continuous coverage for children on Medicaid and CHIP.People AffectedAs of April 2021, there were 39 million children enrolled in Medicaid and CHIP (nearly half of all enrollees). As of January 2020, 31 states provide 12-month continuous eligibility to children in either Medicaid or CHIP. A recent MACPAC report found that the overall mean length of coverage for children in 2018 was 11.7 months, and also that rates of churn (in which children dis-enroll and reenroll within a short period of time) were lower in states that had adopted the 12-month continuous coverage option and in states that did not conduct periodic data checks. Another recent report shows that children with gaps in coverage during a year are more likely to be children of color with lower incomes.Budgetary ImpactCBO has not yet published budgetary estimates for this section of the Build Back Better Act.Given that the length of coverage for children in Medicaid is already high (mean of 11.7 months), more than half of all states already have a continuous coverage policy in place, and costs for children are generally lower compared to other eligibility groups, new federal costs could be moderate.

In addition, reducing churn could modestly reduce Medicaid administrative costs.8. Permanent Extension of the Children’s Health Insurance Program (CHIP)Provision DescriptionUnder current law, Medicaid is the base of coverage for low-income children. CHIP complements Medicaid by covering uninsured children in families with incomes above Medicaid eligibility levels. Unlike Medicaid, federal funding for CHIP is capped and provided as annual allotments to states.

CHIP funding is authorized through September 30,2027. While CHIP generally has bipartisan support, during the last reauthorization funding lapsed before Congress reauthorized funding.Section 30801 of the Build Back Better Act would permanently extend the CHIP program.People AffectedAs of April 2021, there were 6.9 million people (mostly children) enrolled in CHIP.Budgetary ImpactCBO has not yet published budgetary estimates for this section of the Build Back Better Act.Federal CHIP funding in Fiscal Year (FY) 2020 for the states was $17.0 billion. Since CHIP is authorized through FY 2027, CBO estimates would only account for costs in FY 2028 – FY 2031 (the current ten-year window). When CHIP was reauthorized through FY 2027, CBO estimated that this would result in net fiscal savings to the federal government because without CHIP, other alternatives would have higher federal costs and because of expected changes in the federal match rate back to traditional CHIP match rates.9.

Medicaid Home and Community Based Services and the Direct Care WorkforceProvision DescriptionMedicaid is currently the primary payer for long-term services and supports (LTSS), including home and community-based services (HCBS), that help seniors and people with disabilities with daily self-care and independent living needs. There is currently a great deal of state variation as most HCBS eligibility pathways and benefits are optional for states.Sections 30711-30715 of the Build Back Better Act would create the HCBS Improvement Program, which would provide a permanent 7 percentage point increase in federal Medicaid matching funds for HCBS. To qualify for the enhanced funds, states would have to maintain existing HCBS eligibility, benefits, and payment rates and have an approved plan to expand HCBS access, strengthen the direct care workforce, and monitor HCBS quality. The bill includes some provisions to support family caregivers.

In addition, the Act would include funding ($130 million) for state planning grants and enhanced funding for administrative costs for certain activities (80% instead of 50%).Sections 30721 and 30722 of the Build Back Better Act would make the Money Follows the Person (MFP) program and the ACA HCBS spousal impoverishment protections permanent.People AffectedThe majority of HCBS are provided by waivers, which served over 2.5 million enrollees in 2018. There is substantial unmet need for HCBS, which is expected to increase with the growth in the aging population in the coming years. Nearly 820,000 people in 41 states were on a Medicaid HCBS waiver waiting list in 2018. Though waiting lists alone are an incomplete measure, they are one proxy for unmet need for HCBS.

Additionally, a shortage of direct care workers predated and has been intensified by the erectile dysfunction treatment kamagra, characterized by low wages and limited opportunities for career advancement. The direct care workforce is disproportionately female and Black.Over 101,000 seniors and people with disabilities across 44 states and DC moved from nursing homes to the community using MFP funds from 2008-2019. A federal evaluation of MFP showed about 5,000 new participants in each six month period from December 2013 through December 2016, indicating a continuing need for the program.A KFF survey found that, as of 2018, 14 states expected that allowing the ACA provision to expire would affect Medicaid HCBS enrollees, for example by making fewer individuals eligible for waiver services.Budgetary ImpactCBO has not yet published budgetary estimates for these sections of the Build Back Better Act.The House Energy and Commerce Committee markup of the bill described the cost to the federal government as $190 billion. This is less than the $400 billion originally proposed by President Biden.

While the program requirements are not the same, CBO previously estimated that the American Rescue Plan Act’s 10 percentage point increase in federal matching funds for Medicaid HCBS for 1 year would increase federal costs by about $12.7 billion.10. Paid Family and Medical LeaveProvision DescriptionThe U.S. Is the only industrialized nation without a minimum standard of paid family or medical leave. Although six states and DC have paid family and medical leave laws in effect, and some employers voluntarily offer these benefits, this has resulted in a patchwork of policies with varying degrees of generosity and leaves many workers without a financial safety net when they need to take time off work to care for themselves or their families.Section 130001 of the Build Back Better Act would guarantee 12 weeks per year of paid family and medical leave annually to all workers in the U.S.

Who need time off work to welcome a new child, recover from a serious illness, care for a seriously ill family member, or for certain military-related reasons. Also included is three days of paid bereavement leave. The progressive benefits formula means that that the amount of pay replaced while on qualified leave is higher for workers with lower wages, with 85% wage replacement for individuals earning about $15,080/year. While all workers taking qualified leave would be eligible for at least some wage replacement, earnings above $250,000/year are not included in the benefit formula.People AffectedAccording to the Bureau of Labor Statistics, one in five (21%) workers have access to paid family leave through their employer.

It is estimated that 53 million adults are caregivers for a dependent child or adult and 61% of them are women. Sixty percent (60%) of caregivers reported having to take a leave of absence leave from work or cut their hours in order to care for a family member. Workers who take leave do so for different reasons. Half (51%) reported taking leave due to their own serious illness, one-quarter (25%) for reasons related to pregnancy, childbirth, or bonding with a new child, and one-fifth (19%) to care for a seriously ill family member.

In total, four in ten (42%) reported receiving their full pay while on leave, one-quarter (24%) received partial pay, and one-third (34%) received no pay.Budgetary ImpactCBO has not yet published budgetary estimates for this section of the Build Back Better Act.However, unofficial estimates reportedly put the cost at $494 billion over ten years. A 2019 CBO estimate of the proposed Democratic-led FAMILY Act, which is similar to the current proposal, estimated that program would cost $547 billion over ten years.SOURCE. KFFKey FindingsThe October KFF Health Tracking Poll finds one in five adults in the U.S. Report receiving ongoing support for daily activities such as bathing, dressing, or remembering medications, and a similar share say they are providing those type of services for a close friend or family member.

About one in five adults (18%) also say they or a family member need either new or additional support from paid nurses or aides beyond what they are currently getting. The most common reason why people haven’t gotten the support they need is cost. More than three-fourths of those who say they need more help (14% of all adults) say “not being able to afford the cost of the care” is a reason why they or their family member has not received the additional support from paid nurses or aides.Many unpaid caregivers say providing support to friends or family members has caused them to worry or stress (77%), experience worsening of their own mental health (50%), financial strain due to inability to work (42%), or worsening of their own physical health (38%). Unpaid caregivers are more likely to be racial and ethnic minorities, those with lower education, and report lower levels of household income.Significant shares of older adults in the U.S.

Report difficulty paying for various aspects of health care, especially services not generally covered by Medicare. Four in ten older adults (41%) report difficulty paying for dental care while three in ten report difficulty affording hearing or vision care (30%). Dental, vision, and hearing coverage are three benefits not generally covered by Medicare but are part of Democratic lawmakers’ proposals as part of the reconciliation spending package.Many older adults who are eligible for Medicare also report putting off or foregoing medical care due to costs. While Medicare helps older adults pay for routine doctor visits and hospital stays, substantial shares of lower income older adults report putting off or foregoing services not covered by Medicare.

Overall, more than four in ten older adults in households earning less than $40,000 annually report delaying or going without some form of medical care over the past year due to costs (compared to 24% of older adults with household incomes over $40,000), including dental care (34%), vision care (20%), and hearing services including hearing aids (16%).With substantial shares of the public reporting financial strains associated with help with everyday activities for themselves or family members, and seniors reporting difficulty paying for some health care expenses, the latest KFF poll finds broad support for many of the proposals in the reconciliation package being currently discussed in Congress.Home And Community Based ServicesOne in five adults, including 27% of adults 65 and older, say they are currently receiving ongoing support with everyday activities from either a family member (19%), a friend (11%), or paid nurses or aides (5%). Additionally, nearly four in ten (38%) adults say a family member gets ongoing help from at least one of these sources including another family member (30%), paid nurses or aides (16%) or friends (12%). About one in five adults (18%) say they or a family member need either new or additional support from paid nurses or aides beyond what they are currently getting. The most common reason why people haven’t gotten the support they need is cost.

More than three-fourths of those who say they need more help (14% of all adults) say “not being able to afford the cost of the care” is a reason why they or their family member has not received the additional support from paid nurses or aides. Other reasons include not being able to find someone to provide the services (47%, or 8% of all adults), being worried about being exposed to erectile dysfunction (40%, 7% of all adults), being afraid or embarrassed to get help (32%, 6%), or being too busy or unable to find the time to get help (20%, 4%). With many reporting difficulty paying for cost of home and community based care, the poll also gauged support for Democratic proposals to increase funding to Medicaid to pay workers and expand home and community-based services (HCBS). Medicaid is the primary payer for long-term services and supports (LTSS), including home and community-based services (HCBS), that help seniors and people with disabilities with daily self-care and independent living needs.

Majorities across partisans (79% total, 95% of Democrats, 76% of independents, 67% of Republicans) support increased funding to Medicaid to pay workers and expand home and community-based services (HCBS).The toll On Unpaid CaregiversWith Congress discussing possible new tax credits to help with home and community based care, one in five adults (21%) say they are currently providing unpaid support with everyday activities to either a friend or family member, excluding the type of care young children need. Majorities across partisans also favor new tax credit to help people pay for such care (82% total, 94% of Democrats, 80% of independents, 73% of Republicans).The KFF October Tracking Poll finds unpaid caregivers are more likely to be Black or Hispanic (14% and 21%) compared to those who are not unpaid caregivers (10% and 15%). About eight in ten unpaid caregivers to family and friends do not have a college degree, and about half have household incomes under $40,000. Consistent with recent focus groups conducted by KFF, the poll finds most unpaid caregivers (85%, 18% of all adults) report experiencing at least one of several negative outcomes due to their caregiving responsibilities.

Over three-fourths of unpaid caregivers (16% of all adults) say they have experienced stress or worry related to the care of the individual they are caring for, with an additional half (11% of all adults) say they have experienced a worsening of their own mental health as a result of providing this ongoing support. About four in ten (9% of total) say they have experienced financial strain, such as losing a job or having to work reduced hours. A similar share (38% and 8% of total) also say they have experienced a worsening of their own physical health. Expanding Medicare BenefitsWith Congress debating changes to the current Medicare program, eight in ten adults—and nearly all older adults—say Medicare is important to them and their family members.

This includes at least seven in ten adults across partisanship, income groups, and racial and ethnic identity. Significant shares of older adults in the U.S. Report difficulty paying for various aspects of health care, especially services not generally covered by Medicare. Four in ten older adults (41%) report difficulty paying for dental care while three in ten report difficulty affording hearing or vision care (30%).

Two in ten report difficulty affording their prescription drugs. Additionally, one-third report difficulty affording their out-of-pocket health care costs and one in five report the same about their monthly health insurance costs – shares comparable to those who report difficulty affording other household expenses such as rent or mortgage, gasoline, monthly utilities, or food and groceries. Dental services are the most common type of medical care that people have delayed or gone without with about with about one in four (23%) of adults ages 65 and older saying they have put off dental care in the past year due to cost. This is followed by vision services or eyeglasses (15%) and hearing aids (13%).

Dental, vision, and hearing coverage are three benefits not generally covered by Medicare.Few older adults report delaying or going without a doctor’s office visit (6%), hospital services (5%) or mental health care (2%) due to cost. Overall, three in ten adults 65 and older report delaying or going without certain medical care during the past year due to cost (32%). Even among older adults who are eligible for Medicare, those with lower incomes report delaying or going without care at higher rates. More than four in ten older adults in households earning less than $40,000 annually report delaying or going without some form of medical care over the past year due to costs (compared to 24% of older adults with household incomes over $40,000).

While Medicare helps older adults pay for routine doctor visits and hospital stays, substantial shares of lower income older adults report putting off or foregoing dental care (34%), vision care (20%), and hearing services including hearing aids (16%) that are not generally covered by Medicare. A large majority of the public (90%) favor expanding Medicare coverage to include dental, vision, and hearing coverage, including 97% of Democrats, 90% of independents, and 85% of Republicans. This proposal is also largely favored by adults 65 and older, including 96% of those in that age group who identify as Democrats or Democratic-leaning and 82% of their Republican counterparts. Proposals aimed at curbing the price individuals have to pay for their prescription drugs are favored by majorities of the public with at least eight in ten overall and at least three-fourths across partisans saying they favor each of the proposals asked about.

Eighty-eight percent of adults favor limiting how much drug companies can increase the price for prescription drugs each year to not outpace the rate of inflation (including 93% of Democrats, 86% of independents, 89% of Republicans) and a similar share (85%) favor placing an annual limit on out-of-pocket prescription drug costs for people on Medicare (favored by 88% of Democrats, 85% of independents, 84% of Republicans). The proposed changes to Medicare drug negotiations as part of the reconciliation package poll findings were released earlier this week.The Affordable Care ActViews of the 2010 Affordable Care Act are still largely driven by party identification with nearly nine in ten Democrats saying they view the law favorably, while three-fourths of Republicans say they hold an unfavorable view. Independents are slightly more favorable than unfavorable with more than half saying they hold a positive opinion of the ACA. KFF has been polling on the ACA since its passage and since 2017 views have been more favorable than unfavorable but still sharply divided on party lines.

The erectile dysfunction treatment relief bill passed in early March 2021 providing additional financial help for people who buy their own health insurance coverage. Previous KFF polling found that a small minority of those likely eligible for additional financial help or coverage reporting going online to see if they qualify for a different or cheaper health insurance plan.Among those under 65 years old, nine percent of those who are either uninsured or buy their own coverage reported going online in the in the two months before mid-May 2021 to see if they qualify for a different or cheaper health insurance plan or Medicaid as part of the erectile dysfunction treatment relief package. Four months later, the latest KFF polling finds that about one in four (23%) of those likely eligible for this assistance have gone online to see if they qualify, though majorities (75%) still have not. In addition, changes to health insurance coverage provided under the Affordable Care Act continue to be seen through a partisan lens, with overwhelming majorities of Democrats and smaller majorities of Republicans expressing support.

Overall, eight in ten adults favor making permanent the financial help to low- and moderate- income Americans who buy their own health insurance coverage (94% of Democrats, 79% of independents, 63% of Republicans). Three in four favor the federal government stepping in to provide insurance options for lower income people living in states that haven’t expanded their Medicaid programs (94% of Democrats, 76% of independents) but this is supported by a small majority (54%) of Republicans.While the poll finds broad support for many of the Democratic proposed changes to the country’s health care system including the ACA, Medicaid, and Medicare, the poll did not ask about the potential costs and savings associated with each provision, or the size and scope of Democrats’ broader legislative plan, which includes many provisions unrelated to health care. Methodology.